To calculate the risk level for each of the DOC co-morbidities, total DOC-Mood, DOC-Apnea and DOC-Cog are at minimum required. Additional information can be used to refine this risk calculation based on demographic and clinical information (age, sex, height & weight (BMI), and number of years of education). However, inputting this information is optional. If you wish to use only the DOC sub-scores, select the 'QUICK FORM' option. If you wish to use the additional demographic and clinical information select the 'QUICK FORM & CLINICAL VARIABLES' option. If you wish view the full DOC form, select the 'DOC SCREEN' option.Please indicate whether data is for testing purposes or a real patient. The option to document the actions taken/referrals made based on screening results will only appear if data is being entered for a real patient.

DOC Scores
Clinical Variables

DOC Screen

Memory (Registration)
Read list of words, subject must repeat them. Do 2 trials. Do a recall after 5 minutes.
Face Velvet Church Daisy Red
1st trial
2nd trial

DOC Mood1
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure doing things:
Feeling down, depressed, or hopeless:

DOC Apnea2
Yes No
Do you snore loudly (louder than talking, heard through a door, or bother other people)?
Do you often feel tired, fatigued, or sleepy during the daytime?
Has anyone observed you stop breathing during your sleep?
Do you have, or are you being treated for high blood pressure?

Draw a clock (ten past eleven)

Loading Canvas...

Draw Erase

Attempted? Contour: Numbers: Hands:

What is the similarity between: (e.g. banana - orange = fruit) A train and a bicycle? A watch and a ruler?

Memory (Delayed Recall)
What were those 5 words?
Face Velvet Church Daisy Red
Without cue
Category cue
Multiple choice cue

Modified/Combined from:
1PHQ-2: Hajek VE et al. Brief assessment of cognitive impairment in patients with stroke. Arch Phys Med Rehabil. 1989 Feb;70(2):114-7.
2STOP: Chung F et al. STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008 May;108(5):812-21.74.
3MoCA: Nasreddine ZS et al. The montreal cognitive assessment, MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. MoCA copyright of the adapted version: Z. Nasreddine MD. Adapted by Swartz et al., 2013.