Date: ……..

Reason for the visit: Dementia (new consult or follow up)

Patient was accompanied by: ………


******(A brief explanation of when symptoms started and progression of events)******

Social support: 
  • Patient lives with:
  • Qualify for future home health or nursing home?
  • Financial supervision:
  • Advance directives:
  • Driving:
Current Medications: 
  • Memory:
  • Psychiatric:
  • Sleep:


Cognitive function screening: 


  • Behavioral symptoms:
    • Impulsivity :
    • Disinhibition:
    • Inappropriate actions:
    • Insight in current illness:
    • Change in personality: being more quit/boisterous, irritable, short-tempered
    • Impaired reasoning:
    • Abstraction:
  • Speech production:
    • Fluency:
    • Naming:
    • Repetition:
  • Frontal release reflexes: 
    • Grasp, palmomental, glabellar, snout, head retraction reflex


  • Memory:
    • Recent:
    • Remote:
  • Speech comprehension:
  • Emotions:


  • Somatosensory: astereognosis, graphethesia
  • Calculation:
  • Visuospatial:
  • Apraxia:
  • Dyslexia:
  • Impaired sequencing:
Non-cognitive symptoms Screening: 
  • Psychiatric: Depression, anxiety, delusions or hallucinations
  • Sleep problems: insomnia, REM disorder
  • Autonomic symptoms: urinary, bowel or sexual
Rest of neurological exam:

Cranial Nerve: Pupils are equal, round, and reactive to light. Visual fields are intact to confrontation. Ocular movements are intact. Face is symmetric at rest and with activation with intact sensation throughout. Hearing intact to finger rub bilaterally. Muscles of tongue and palate activate symmetrically. No dysarthria. Strength is full in sternocleidomastoid and trapezius bilaterally.

Motor: Muscle bulk and tone are normal. Strength is 5/5 in all four extremities both proximally and distally. Intact fine motor movements bilaterally. There is no pronator drift or satelliting on arm roll.

Sensory: Sensation is intact to light touch, pinprick, vibration, and proprioception throughout. Romberg is negative.

Reflexes: 2+ and symmetric at the biceps, triceps, brachioradialis, patella, and Achilles bilaterally. Plantar response is flexor bilaterally.

Coordination: No dysmetria on finger-nose-finger or heel-knee-shin. Normal rapid alternating movements. Fast finger tapping with normal amplitude and speed.

Gait: Narrow based with normal stride length and good arm swing bilaterally. Able to walk on heels, toes, and in tandem.

How to examine for cognitive dysfunction:


  • Behavioral symptoms:
    • Impulsivity:  “Can’t control himself, loss of the self-braking system” as:
      • Fidgeting, squirming in seats, talking nonstop
      • Have difficulty waiting for things they want
      • Often interrupts conversations or others’ activities
      • Smoking, alcohol use, gambling
    • Disinhibition “disregard for social convention” as eating with one’s fingers in public, using obscene language or making inappropriate sexual remarks.
    • Insight in current illness: denies any memory or behavioral problems.
    • Change in personality: being more quit/boisterous, irritable, short-tempered
    • Impaired reasoning: ask the patient how he will behave in different situations (if there is a fire in house, if he found a wallet..)
    • Abstraction: ask the patient to interpret “Don’t cry over spilled milk”
  • Speech production:
    • Fluency
    • Naming: sometimes it may be confusing if it is a naming problem or memory problem. Ask the patient to name only common objects (Pen, paper, palm, finger, finger nail). If patient could name the palm but not finger or finger nail it points to words dysnomia rather than memory. 
    • Repetition: start with simple sentence as “Today is a nice day” then switch to tongue twisters as “No Ifs ands or buts” 
  • Frontal release reflexes: 
    • Grasp
    • Palmomental: scratching across the palm will cause contraction of ipsilateral mentalis muscle.
    • Glabellar: persistent blinking with tapping over the glabella without habituation.
    • Snout: patient tends to snout when any object touch his lips.
    • Head retraction reflex: tapping just below the nose (above the upper lip) will cause sudden marked head retraction.


  • Memory:
    • Recent: 3 word recall after 5 minutes
    • Remote: naming previous presidents
  • Speech comprehension: ability to follow 3 step commands
  • Emotions: apathy, lack of sympathy


  • Somatosensory: astereognosis, graphethesia
  • Calculation: serial 7 substration
  • Visuospatial: draw 2 interlacing triangles or pentagons.
  • Apraxia: ask show me how do you brush your teeth, how you comb your hair, how do you strike a match and blow it off, how
  • Dyslexia: impaired reading
  • Impaired sequencing: ask patient to draw alternating triangles and squares, Go -No Go test.