| RPT |
.| .| General Practitioner Assessment of Cognition| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | GPCOG Score: <-GPCOG Score->| | Low scores indicate cognitive impairment, range 0 to 9.| 9
No significant cognitive impairment and further testing not necessary.| 5-8 More information required.| 0-4 Cognitive impairment is indicated.| | Questions and Answers| | 1. What is
the date? (Answer must be exact.)| <*Answer_5527*>| 2. Please draw a clock on the paper provided. Mark in all the numbers to indicate the hours of a clock (Correct: the numbers 12, 3, 6, and 9
should be in the correct quadrants of the circle and the other numbers should be approximately correctly placed.) | <*Answer_5528*>| 3. Please mark in hands to show 10 minutes past eleven
o'clock, 11:10. (Correct: the hands should be pointing to the 11 and the 2, but do not penalize if the respondent fails to distinguish the long and short hands.) | <*Answer_5529*>| 4. Can you
tell me something that happened in the news recently? (Correct: Must be in the last week. Extensive details are not required but a general answer without details, e.g., war, lots of rain, after
prodding, is incorrect.) | <*Answer_5530*>| 5. Recall items| 5A. John| <*Answer_5531*>| 5B. Brown| <*Answer_5532*>| 5C. 42| <*Answer_5533*>| 5D. West (Street)|
<*Answer_5534*>| 5E. Kensington| <*Answer_5535*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.
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