1. WHEN AND WHERE BORN? Date dd/mm/ yyyy Place city/province (5)
dd (1‚0)‚mm (1‚0)‚ yyyy (1‚0)‚ city/town (1‚0)‚ province (1‚0)
2. REGISTRATION (3)
THREE WORDS (Say the 3 words listed below‚ then ask the person to repeat them. Repeat until correct but only score the first attempt)
· Shoes (1 0)
· Blue (1 0)
· Modesty (1 0)
3. MENTAL REVERSAL (7)
COUNTING and WORLD BACKWARDS
COUNTING FORWARDS 5 to 1 (write their answer)
· Accurate (2)
· 1 or 2 errors / misses (0 1)
SPELL “WORLD”
“World” backwards (print letters) D L R O W (0 1 2 3 4 5)
Give one point for each correct answer
4. FIRST RECALL (9)
Ask the person to recall the 3
· Spontaneous recall: Shoes (3)
· Cue: Something to wear (2)
· Multiple: Shirt‚ shoes‚ socks (1)
· Missed completely (0)
· Spontaneous recall: Blue (3)
· Cue: A colour (2)
· Multiple: Black‚ brown‚ blue (1)
· Missed completely (0)
·
· Spontaneous recall: Modesty (3)
· Cue: A good personal quality (2)
· Multiple: Modesty‚ charity‚ honesty (1)
· Missed completely (0)
5. TEMPORAL ORIENTATION (15)
Today’s date
· Accurate (3)
· Missed by 1 or 2 days (2)
· Missed by 3–5 days (1)
· Missed by more than 5 days (0)
Month
· Accurate or within 5 days (2)
· Missed by 1 month (1)
· Missed by more than a month (0)
Year
1. Accurate (8)
2. Missed by 1 year (4)
3. Missed by 2–5 years (2)
4. Missed by more than 5 years (0)
Day of week
· Accurate (1)
· Missed (0)
Season
· Accurate or within a month (1)
· Missed (0)
6. SPATIAL ORIENTATION (5)
· Province (2 0)
· Country (1 0)
· City or town (1 0)
· Hosp.‚ store‚ home (1 0)
7. NAMING (5)
Ask the person to name the following:
· Forehead (1 0)
· Elbow (1 0)
· Chin (1 0)
· Knuckle (1 0)
· Shoulder (1 0)
8. FOUR-LEGGED ANIMALS (10)
(30 SECONDS) 1 POINT EACH
Ask the person to name as many 4 legged animals as they can in 30 seconds. The maximum score is 10.
9. SIMILARITIES (6)
Ask the person how an Arm and Leg are similar.
Arm-leg
· Limbs‚ extremities (2)
· Body‚ parts‚ bend‚ move‚ joint (1)
· Very weak similarity or no similarity (0)
Laughing-crying
· Feeling‚ emotion (2)
· Expressions‚ sounds‚ relieve tension (1)
· Very weak similarity or no similarity (0)
Eating-sleeping
· Necessary bodily functions (2)
· Bodily functions‚ relaxing‚ good for you (1)
· Very weak similarity or no similarity (0 )
10. REPETITION (5)
I would like to go home (out)
· Correct (2)
· 1 or 2 missed/wrong words (1)
· More than 2 missed/wrong words (0)
· No ifs (1 0)
· ands (1 0)
· or buts (1 0)
11. READ AND OBEY “CLOSE YOUR EYES” (Use Cue Card) (3)
· Obeys without prompting 3
· Obeys after prompting (2)
· Read aloud only (1)
· None of the above (0)
12. WRITING (5)
(1 minute)
Ask the person to write on the next page: (I) would like to go home (out) (0 1 2 3 4 5)
13. COPYING TWO PENTAGONS (1 minute) (10)
Ask the person to copy the design on the next page.
· 5 approx equal sides: Pentagon 1(4)‚ Pentagon 2 (4)
· 5 unequal (2:1) sides: Pentagon 1(3)‚ Pentagon 2 (3)
· Other enclosed figures: Pentagon 1(2)‚ Pentagon 2 (2)
· 2 or more lines: Pentagon 1(1)‚ Pentagon 2 (1)
· Less than 2 lines: Pentagon 1(0)‚ Pentagon 2 (0)
Intersection
· 4 corners (2)
· Not 4 corner enclosure (1)
· No intersection or no enclosure (0)
14. THREE STAGE COMMAND (3)
Ask the person to follow a 3 stage command: ‘Take a piece of paper in your left/right hand‚ fold it in half‚ and hand it back to me’.
· Take this paper with your . . .
· Left/right hand (1 0)
· fold it in half (1 0)
· and hand it back to me (1 0)
15. SECOND RECALL (9)
Ask the person to recall the 3 words from 4th question.
· Spontaneous recall: Shoes (3)
· Cue: Something to wear (2)
· Multiple: Shirt‚ shoes‚ socks (1)
· Missed completely (0)
· Spontaneous recall: Blue (3)
· Cue: A colour (2)
· Multiple: Black‚ brown‚ blue (1)
· Missed completely (0)
·
· Spontaneous recall: Modesty (3)
· Cue: A good personal quality (2)
· Multiple: Modesty‚ charity‚ honesty (1)
· Missed completely (0)
