| RPT |
|Functional Assessment Staging
|Gender: <.Patient_Gender.>
|
|FAST Stage: <-Stage->
|
| Stage 1: Normal adult
| Stage 2: Normal older adult
| Stage 3: Early dementia
| Stage 4: Mild dementia
| Stage 5: Moderate dementia
| Stage 6: Moderately severe dementia
|
| Stage 7: Severe dementia
|
|Questions and Answers
|
|<*Answer_7771*>
|<*Answer_7772*>
|<*Answer_7773*>
|<*Answer_7774*>
|<*Answer_7775*>
|<*Answer_7776*>
|Date Given: <.Date_Given.>
|<*Answer_7777*>
|<*Answer_7778*>
|<*Answer_7779*>
|<*Answer_7780*>
|<*Answer_7781*>
|<*Answer_7782*>
|<*Answer_7783*>
|<*Answer_7784*>
|<*Answer_7785*>
|<*Answer_7786*>
|Clinician: <.Staff_Ordered_By.>
|
|Copyright (c) 1984 by Barry Reisberg, M.D., Reproduced with permission.
|
|Information contained in this note is based on a self-report assessment and is not sufficient to use alone for
diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other
diagnostic activities and procedures.
|Location: <.Location.>
|
|Veteran: <.Patient_Name_Last_First.>
|SSN: <.Patient_SSN.>
|DOB:<.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
