A.	Cognitive (memory and executive function) symptoms management:
		Needed	If yes, is need met	Notes
A-1	Undiagnosed cognitive symptoms
	Is the PT lacking a diagnosis of dementia? AND Has the person had one or more of the following cognitive or functional changes: Memory Loss Confusion Changes in day-to-day function Is a medical work-up or assessment to diagnose cognitive symptoms needed?	□Yes	□No
		□No	□Partially
			□Fully
A-2	Complex presentation of cognitive symptoms
	Has the PT had a sudden onset or change in cognition or other aspects of mental status? Does the PT have new symptoms that have not been evaluated? Is an evaluation of any complex presentation of cognitive symptoms needed?	□Yes	□No
		□No	□Partially
			□Fully
A-3	Cognitive symptoms management
	Has the PT recently been diagnosed with dementia? Is the PT in the early to middle stages of dementia? Would medication be potentially useful for managing the PT’s cognitive symptoms? Is an evaluation needed to determine whether medication might be useful for reducing cognitive or functional decline?	□Yes	□No
		□No	□Partially
			□Fully