MINI-COG SCREEN

Date: [Date]
Patient: [Name or ID, age]
Given by: [Name and role]
Why screened: [Annual check-up, memory concern from the patient or family, assessment before surgery, or other reason]
Language of testing: [Language used; official translation or interpreter if used]

RESULT
Word list version: [Version number from the official form]
Words recalled: [0 to 3, without cues]
Clock: [Normal, 2 points, or abnormal, 0 points; what was wrong if abnormal]
Total: [0 to 5]
Cut point used: [Under 3, or under 4 for higher sensitivity]
Screen: [Positive or negative]

CONDITIONS ON THE DAY
Hearing and vision: [Hearing aids and glasses in use; any trouble hearing the words or seeing the page]
Language and schooling: [First language, years of schooling, reading and writing if relevant]
Mood and alertness: [Low mood, anxiety, drowsiness, or signs of delirium]
Health and medicines: [Recent illness, pain, new or sedating medicines, alcohol]
Drawing hand: [Tremor, arthritis, weakness, or other limits on drawing]

HISTORY FROM OTHERS
Concerns noticed: [What the patient and a family member or close friend have noticed, and since when]
Daily function: [Medicines, money, driving, cooking, and any recent change]

PLAN
Next step: [Fuller cognitive test, bloodwork, medication review, referral, or repeat screen]
Follow-up: [Date, and who will come with the patient]
Result discussed with: [Patient, family member, or both; how it was explained]

Clinician: [Name, credentials]