If ALL 4 of these statements are checked, please complete the form below: Patient is covered under Traditional Medicare as primary insurance Patient is not currently on hospice Patient is not currently in a nursing home with level 4 care and above Patient has a diagnosis of or suspicion of dementia Patient Name First Last DOB MM slash DD slash YYYY Address Street Address Address Line 2 City State Zip Code Caregiver and/or POA Name PhoneEmail Language preferences for communication needs Has the Patient been diagnosed with dementia? Yes No When? What type of dementia? Alzheimer's FTD Lewy Body Vascular Other/Unknown Provider who diagnosed Name of practice or hospital Patient able to make own medical decisions? Yes No Please explain Does leaving home require considerable and taxing effort? Yes No Please explain Does patient use a wheelchair or walker for mobility? Yes No Functional Status: Please check any/all boxes below that apply. Difficulty with complex tasks like paying bills or preparing meals. Requires assistance in activities such as choosing proper clothing. Needs help getting dressed. Requires assistance with bathing. Needs support with toileting mechanics(flushing, wiping). Unable to speak more than 5 words. Is completely bed bound. Medical History: Does patient have any of the below conditions? Hypertension (high blood pressure) Diabetes (type 1 or type 2) Heart disease (coronary artery disease, heart failure) Chronic obstructive pulmonary disease (COPD) C Stroke or transient ischemic attack (TIA) Asthma Cancer Neurological conditions (e.g., epilepsy, Parkinson’s disease) Kidney disease Liver disease Thyroid disorders Osteoarthritis or rheumatoid arthritis Osteoporosis Other (please specify) Type of cancer Medical history (other) Has Patient been prescribed medications to treat any of the above? Yes No Mental Health History: Does patient have any of the below conditions? Anxiety disorders (e.g., generalized anxiety, panic disorder) Substance use disorders (alcohol, drugs, opioids) Depression or major depressive disorder Bipolar disorder Schizophrenia or other psychotic disorders Post-traumatic stress disorder (PTSD) Personality disorders (e.g., borderline personality disorder) Other (please specify) Mental health history (other) Has Patient been prescribed medications to treat any of the above? Yes No Dementia ScreeningProblems with judgment (e.g., problems making decisions, bad financial decisions, problems with thinking) Yes No Don't Know Less interest in hobbies/activities Yes No Don't Know Repeats the same things over and over (questions, stories, or statements) Yes No Don't Know Trouble learning how to use a tool, appliance, or gadget (e.g., computer, microwave, remote control) Yes No Don't Know Forgets correct month or year Yes No Don't Know Trouble handling complicated financial affairs(e.g., balancing checkbook, income taxes, paying bills) Yes No Don't Know Trouble remembering appointments Yes No Don't Know Daily problems with thinking and/or memory Yes No Don't Know
