SLUMS EXAM RESULT

Date: [Date]
Patient: [Name or ID, age]
Given by: [Name and role; SLU training video watched]
Reason: [Memory concern raised by the patient or family, yearly check, or follow-up of an earlier score]

BEFORE TESTING
Schooling: [Years completed and highest level reached]
Language: [Language used; SLU translation and examiner fluent in it, or English original]
Hearing and vision: [Glasses and hearing aids worn, and whether the patient could see and hear every task]
Alertness: [Alert and at usual baseline, or concerns about delirium, pain, sedation, or recent illness]

SCORE
Total: [0 to 30]
Cutoffs used: [High school education: 27 to 30 normal, 21 to 26 mild neurocognitive disorder, 20 or below dementia; or less than high school: 25 to 30, 20 to 24, 19 or below]
Range: [Normal, mild neurocognitive disorder range, or dementia range]

WHERE POINTS WERE LOST
Domains with errors: [Orientation, recall, attention, calculation, word fluency, visuospatial, executive function]
Observations: [Effort, anxiety, fatigue, self-corrections, anything else that affected the result]

OTHER FINDINGS
Daily function: [What the patient manages alone and what needs help: medicines, money, cooking, shopping, driving]
Collateral history: [Who described changes, with consent, and over how long]
Other causes: [Depression screen, delirium features, sleep, alcohol, medicines that affect thinking, neurological exam]

PLAN
Next step: [Full cognitive assessment, treat another cause first, or no further action]
Labs: [B12, thyroid function, blood count, chemistries, calcium, glucose, others]
Imaging: [Brain CT or MRI, or not needed now and why]
Referral: [Memory clinic, geriatrics, neurology, or neuropsychology, and what was sent]
Driving and safety: [Driving advice, medicines, money, stove, firearms, and who was told]
Repeat SLUMS: [Date, no sooner than 12 months, same language version and cutoff set]

Clinician: [Name, credentials]