| Maximum
Score |
Score |
|
|
| |
|
|
ORIENTATION |
| 5 |
(
) |
|
What is the:
(year) (season) (date)
(day) (month) |
| 5 |
(
) |
|
Where are we:
(state) (county)
(town) (facility) (floor) |
| |
|
|
REGISTRATION |
| 3 |
(
) |
|
Name three objects
and have person repeat them back. Give
one point for each correct answer on the
first trial.
1. _______ 2.
_______ 3. _______
Then repeat them (up to 6x) until all
three are learned.
[Number of trials ____ ] |
| |
|
|
ATTENTION
AND CALCULATION |
| 5 |
(
) |
|
Serial 7's.
Count backwards from 100 by serial
7's. One point for each correct
answer. Stop after 5
answers. [ 93 86
79 72 65 ]
Alternatively spell "world"
backwards. [ D - L - R - O - W ] |
| |
|
|
RECALL |
| 3 |
(
) |
|
Ask fo rthe names
of the three objects learned above.
Give one point for each correct answer. |
| |
|
|
LANGUAGE |
| 9 |
(
) |
|
Name: a pen
(1 point) and a watch (1 point)
Repeat the following: "No ifs,
ands, or buts" (1 point)
Follow a three-stage command:
"Take this paper in your
[non-dominant] hand, fold it in half and
put it on the floor". (3 points)
[1 point for each part correctly
performed]
Read to self and then do: "Close
your eyes" (1 point)
Write a sentence [subject, verb and makes
sense] (1 point)
Copy design [ 5 sided geometric figure; 2
points must intersect]
(1 point) |
| Score:
/30
Alert
Overtly Anxious
Concentration Difficulty
Drowsy |
CLOSE YOUR EYES
|
 |
Sentence: |
