ARMED FORCES RETIREMENT HOME
Page | 5 of 6 ME 01-2021
MD/DO/NP/PA initial EACH page: X
Prior Versions No Longer Valid
COGNITIVE, BEHAVIORAL, MENTAL HEALTH QUESTIONS - Provide an explanation for any true statements and mark any specific behaviors/items that apply to the patient.
Indicate if any of the following are TRUE (primary care physician may attach letter or comments to clarify responses)
Demonstrates signs of cognitive decline such as requiring cues/support to perform daily tasks like basic shopping,
managing medications, healthcare decisions, nutrition, or ability to navigate independently -- gets lost, wanders…
Demonstrates decline in the ability to communicate clearly, remember accurately, or make reasonable decisions; and/or
shows poor judgement/risk assessment, poor listening/reading comprehension, or has difficulty in expressing ideas
-- forgetting terms, losing train of thought, repetition of statements …
Demonstrates signs of confusion or lack of orientation (person, place, date/time, or situation); if so, describe…
f decline in cognition is noted in #1, #2, or #3 above, have you completed a cognitive assessment (i.e.: MoCA, MMSE…)?
Assessment: Score: Date: (attach copy if available)
Indicate whether these statements are true or false for this individual (within the past 12 months)
Any incidents/behaviors taking place over 12 months ago that have not been resolved or pose any risk should also be disclosed.
Does the patient drink alcohol? How many servings of alcohol does the patient drink on an average week?
Drinks 7+ servings of alcohol per week (daily habit) and/or occasionally has 4+ servings at a time (binge)? Describe habits…
7. Do any of the following statements apply to the patient’s use of drugs, alcohol, substances, or other behaviors? If any are true
please indicate the substance/behavior and mark any specific items (underline/circle) that apply to their behavior.
Has the patient EVER been counseled, sought help, or been diagnosed with AUD, SUD, or another addiction? If true, has the
condition been active within the past 12 months? Describe any active use or remissions shorter than 12 months.
☐ YES — active or in early remission ☐NO — in remission longer than 12 months ☐ N/A — no history of this
Indicate whether these statements are true or false for this individual (occurring within the past 12-24 months)
Any incidents/behaviors taking place over 2 years ago that have not been resolved or pose any risk should be disclosed.
10. Has decreased participation in usual activities, lost interest/quit caring, is bored/listless, lacks enjoyment/motivation; or
has had a significant change in the level of self-isolation, sleep disturbances, personal grooming, or disorganization.
a. Hazardous use - driving intoxicated, falls/injuries, overdosing/black-outs, reckless/illegal activities, risky/erratic behaviors, violence...
b. Use aggravates or causes physical/mental health problems - cirrhosis, COPD, hypertension, cognitive loss, depression, anxiety...
c. Neglects major social/work roles, has developed cravings, or expends a lot of effort/time planning, obtaining, using, recovering...
d. Has had
conflicts due to their behavior or has been withdrawing from activities which exclude the substance/behaviors
e. Has failed at attempts to control behavior, has been increasing quantity/time spent, has developed tolerance, or experiences withdrawal
Has continued to use any alcohol, drugs, tobacco or other substance against medical/professional advice or even when the patient
is aware of adverse drug interactions, specific use-related illnesses, medical complications, cognitive issues, falls/injuries,
psychological/social problems, or otherwise detrimental, dangerous, or hazardous consequences of such use. Explain...