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Confidential report

M3 Dementia Review

Name: Sample Report

Birthdate: 01/15/1954

Date of report: 08/17/2026

Three check-ins, twelve weeks apart, four instruments. IQCODE eased to 3.38 and IADL-C to 1.36, both still over their lines; the M3 total fell from 45 (about 36% above 33) to 37 (about 12% above) to 29 today, below the line; pain eased from 6 to 3. Page 2 shows all three.

The four instruments — today

IQCODE (informant)

3.38 of 5

Decline

Decline warranting evaluation

Cognitive change — against ten years ago.

IADL-C (informant)²

1.36 of 8

MCI boundary

At or above the MCI boundary

Everyday function — money and self-management.

M3 Total Score

29 of 108

Mild

Mood — depression, anxiety, PTSD, bipolar.

DVPRS Pain (0–10)

3

Mild

Pain — and its effect on sleep, mood, activity.

Four-Line Need Count 2 of 4 lines — cognition and function (4 of 4 on 3/2/2026 and 5/25/2026)

Cognition and function: 2 of 2 · steady since 5/25/2026

IQCODE 3.38 line 3.30 · 0.08 aboveover

IADL-C 1.36 line 1.29 · 0.07 aboveover

Mood and pain: 0 of 2 · better since 5/25/2026

M3 29 line 33 · 4 points below (about 12%)under

DVPRS pain 3 line 5 · 2 points belowunder

A count, not a score: each instrument against its own published line, never added or averaged. Gateway questions (Q5, Q24–27) today: negative, no flag¹ — always shown on their own, never in the count. Information for the physician conversation; the physician decides.

M3 symptom severity scores

Depression

10

of 28

Mild

Anxiety

13

of 48

Mild

PTSD

5

of 16

Mild

Bipolar

3

of 16

Low

Functional impairment

Q5I have had thoughts of suicide0 · Not at all

Q24Symptoms interfere with my work or school1 · Rarely

Q25Symptoms affect my relationships with friends or family1 · Rarely

Q26Symptoms have led to my using alcohol to get by1 · Rarely

Q27Symptoms have led to my using other substances0 · Not at all

¹ Gateway: the gateway questions (thoughts of suicide — Q5; functional impairment and substance use — Q24–Q27) are reviewed individually. A positive response on any gateway question warrants clinical follow-up regardless of the total score.

² IADL-C: shown for example only — a licence from Washington State University has been requested and is not yet granted. The IQCODE is used with Professor Jorm’s permission and is never billed.
This report is a screening aid, not a diagnosis. Please review the results with your clinician. · Page 1 of 4

If you are having thoughts of suicide or are in crisis, call or text 988 (Suicide & Crisis Lifeline) any time, day or night, or go to the nearest emergency room.

M3 Mental Health | m3mentalhealth.org/dementia

Confidential report

M3 Dementia Review

Name: Sample Report

Birthdate: 01/15/1954

Date of report: 08/17/2026

Your four instruments over time

answered by a family member or close friendanswered by the personthe published line — the washed band above it is over the line

Each row keeps its own published line and its own scale — IQCODE 1–5, IADL-C 1–8, M3 0–108, DVPRS 0–10 — so the four are never drawn on one axis, added or averaged. The table below carries every number.

Three check-ins, twelve weeks apart

Date	IQCODE line 3.30	IADL-C² line 1.29	M3 total line 33	Depression · Anxiety · PTSD · Bipolar	DVPRS pain right now	Four-Line Need Count
3/2/2026	3.62	1.58	45 Moderate about 36% above 33	15 · 20 · 8 · 4	6 Moderate	4 of 4 cog. 2 · mood/pain 2 gateway positive¹
5/25/2026 (+12 weeks)	3.50	1.47	37 Moderate about 12% above 33	13 · 16 · 6 · 4	5 Moderate	4 of 4 cog. 2 · mood/pain 2
8/17/2026 (+24 weeks)	3.38	1.36	29 Mild below 33	10 · 13 · 5 · 3	3 Mild	2 of 4 cog. 2 · mood/pain 0

The IQCODE (1–5) and IADL-C (1–8) are answered by a family member or close friend and have their own scales; both eased across the three check-ins but stayed over their lines. The need count is how many of the four are at or over their own line — a count, not a score; gateway answers are shown on their own. Green 0–4 mild · yellow 5–6 moderate · red 7–10 severe.

Top symptoms by category

0Not at all 1Rarely 2Sometimes 3Often 4Most of the time

Depression

Q1I feel sad, down in the dumps or unhappy2

Q2I can't concentrate or focus2

Anxiety

Q10I have attacks of anxiety or panic2

Q8I feel tense, anxious or can't sit still1

PTSD

Q13I have nightmares or flashbacks2

Q14I am jumpy or feel startled easily1

Bipolar

Q20I have more energy than usual1

Q21I have felt unusually irritable or angry1

This report is a screening aid, not a diagnosis. Please review the results with your clinician. · Page 2 of 4

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Confidential report

Answers to the questions — M3 and DVPRS

Name: Sample Report

Birthdate: 01/15/1954

Date of report: 08/17/2026

Over the last two weeks or more, have you noticed the following? (Today’s check-in, 8/17/2026.)

Depression symptomsMajor Depression

1I feel sad, down in the dumps or unhappy2

2I can't concentrate or focus2

3Nothing seems to give me much pleasure2

4I feel tired; have no energy1

5I have had thoughts of suicide0

6aI have difficulty sleeping2

6bI sleep too much1

7aI have lost some appetite1

7bI am eating more0

Anxiety symptomsGeneralized Anxiety (Q8–9) · Panic Disorder (Q10–11) · Social Anxiety (Q12)

8I feel tense, anxious or can't sit still1

9I feel worried or fearful1

10I have attacks of anxiety or panic2

11I worry about dying or losing control1

12I am nervous or shaky in social situations1

PTSD symptomsPost-Traumatic Stress Disorder

13I have nightmares or flashbacks2

14I am jumpy or feel startled easily1

15I avoid places that remind of a bad experience1

16I feel dull, numb, or detached1

Other anxiety symptomsObsessive-Compulsive Disorder

17I can't get certain thoughts out of my mind1

18I must repeat certain acts or rituals0

19I feel the need to check and recheck things1

Bipolar symptomsBipolar Disorder (unstable mood)

20I have more energy than usual1

21I have felt unusually irritable or angry1

22I have felt unusually excited, revved up or high1

23I have needed less sleep than usual0

Functional impairmentwhether any of the above symptoms… (Q5 also reviewed here)

24…interferes with my work or school1

25…affects my relationships with friends or family1

26…has led to my using alcohol to get by1

27…has led to my using other substances0

Legend — answer scale

0Not at all

1Rarely

2Sometimes

3Often

4Most of the time

Legend — categories

Depression (Q1–7)

Anxiety (Q8–19, including the PTSD items)

PTSD (Q13–16)

Bipolar (Q20–23)

Functional impairment (Q5, Q24–27)

DVPRS pain scale (0–10)

3Pain right now. “Sometimes distracts me”

3Activity. Interfered with usual activity, past 24 hours

2Sleep. Interfered with sleep, past 24 hours

3Mood. Affected mood, past 24 hours

3Stress. Contributed to stress, past 24 hours

The pain score is the first number: 3 Mild (it was 6, then 5). The four past-24-hour answers are shown one by one and never averaged. Bands: 0 no pain · green 1–4 mild · yellow 5–6 moderate · red 7–10 severe.

Other symptoms to ask about

Depression: feelings of worthlessness or excessive guilt; psychomotor agitation or retardation; aches and pains; recurrent thoughts of death or suicide

GAD: muscle tension; aches and pains

Panic Disorder: palpitations, tachycardia, dyspnea, choking feeling, chest pain or discomfort, dizziness, light-headedness; sweating, hot or cold flashes; trembling, paresthesias; persistent fear of future attacks; a change in behavior related to the attacks; feeling of unreality (derealization), feeling detached from oneself, fear of losing control or of going crazy. Consider Agoraphobia: anxiety or panic associated with “unsafe” locations

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Confidential report

Answers to the questions — IQCODE and IADL-C

Name: Sample Report

Birthdate: 01/15/1954

Date of report: 08/17/2026

Answered by a family member or close friend who knows the person well (the informant). Today’s check-in, 8/17/2026; the answers were the same at all three check-ins.

IQCODE — short form, 16 questionscompared with 10 years ago

1Remembering things about family and friends — occupations, birthdays, addresses3 · Not much change

2Remembering things that have happened recently4 · A bit worse

3Recalling conversations a few days later4 · A bit worse

4Remembering his/her address and telephone number3 · Not much change

5Remembering what day and month it is4 · A bit worse

6Remembering where things are usually kept4 · A bit worse

7Remembering where to find things which have been put in a different place from usual3 · Not much change

8Knowing how to work familiar machines around the house3 · Not much change

9Learning to use a new gadget or machine around the house4 · A bit worse

10Learning new things in general3 · Not much change

11Following a story in a book or on TV4 · A bit worse

12Making decisions on everyday matters3 · Not much change

13Handling money for shopping3 · Not much change

14Handling financial matters — the pension, dealing with the bank3 · Not much change

15Handling other everyday arithmetic problems — knowing how much food to buy, knowing how long between visits from family or friends3 · Not much change

16Using his/her intelligence to understand what's going on and to reason things through3 · Not much change

IADL-C — 11 questions²everyday activities, and whether aids are used

1Can organize complex activities such as travel, running errands, or participation in group activities2

2Can plan an efficient sequence of stops on a shopping trip2

3Can manage a budget and business affairs1

4Able to prioritize and complete tasks in order of importance1

5Remembers whether bills were paid2

6Can fill out insurance claims and doctor's records, including providing health history1

7Keeps financial records organized1

8Can find way back to a meeting spot in the shopping mall or other location2

9Appropriately recalls where items were placed and where to find items1

10Balances a check book or credit card statement1

11Check answering machine or voicemail messages and appropriately returns calls1

IQCODE — answer scale

1Much improved

2A bit improved

3Not much change

4A bit worse

5Much worse

Score: the average of the 16 answers — today 3.38. 3.00 or below no meaningful change · 3.01–3.29 watch · 3.30–3.59 decline warranting evaluation · 3.60 and above the secondary-care threshold. Jorm 1994.

IADL-C — answer scale

1Does it as well as ever — no aids

2Does it as well as ever — using aids or strategies

3Some decline — using aids or strategies

4Some decline — no aids

5Sometimes needs help

6Usually needs help

7Always needs help

8Not able to do this any more

—Never had to do this

—No basis for judgment

Score: the mean of the answered items — today 1.36, with aids or strategies used on 4 of 11. Below 1.29 below the boundary · 1.29 and above at or above the MCI boundary · 4.41 and above at or above the dementia boundary. Schmitter-Edgecombe 2014; boundaries Rahman 2025.

Reading the two together

Both informant scores sit just over their lines and did not move across 24 weeks, while the M3 total and pain improved. This is information for the conversation with the physician, not a diagnosis; the physician decides what, if anything, follows.

² IADL-C: shown for example only — a licence from Washington State University has been requested and is not yet granted. IQCODE used with Professor Jorm’s permission and never billed. · This report is a screening aid, not a diagnosis. · Page 4 of 4