Brief Neurocognitive Assessment

Instructions: click in the circles indicated for each item (e.g., right / wrong).

DATE      TIME (24hr) 

right / wrong

Orientation to Person:
[]   [] 1. What is your last name?
[]   [] 2. What is your first name?
[]   [] 3. What is your birthday?
[]   [] 4. What is your birth year?
[]   [] 5. How old are you?    PERSON

Recollection of personal information:
[]   [] 6. In what county/city were you born?
[]   [] 7. In what state (country if not US) were you born?
[]   [] 8. What is your mother's maiden name?
[]   [] 9. How far did you go in school (years of education)?
[]   [] 10. What is your address (or phone number)?    PERSONAL HISTORY

Orientation to place:
[]   [] 11. What is the name of this clinic (place)?
[]   [] 12. What floor are we on?
[]   [] 13. What city are we in?
[]   [] 14. What county are we in?
[]   [] 15. What state are we in?    PLACE

Orientation to time:
[]   [] 16. What is today's date? (exact only)
[]   [] 17. What is the month?
[]   [] 18. What is the year?
[]   [] 19. What day of the week is today?
[]   [] 20. What season is it?    TIME/DATE

Recollection of historical information (PRESIDENTS)
[]   [] 21. Who is the President of the US?
[]   [] 22. Who was the President before him?
[]   [] 23. Who was the President before him?
[]   [] 24. Who was the first President of the US?
[]   [] 25. Name another US President?    PRESIDENTS:

Get the participant's attention, then say: "I am going to say five words that
I want you to remember now and later. The words are:

              SHIRT    SPOON    CHAIR    LAMP    HOUSE

Please say them for me now"
(Give the participant 3 tries to repeat the words. If unable after 3 tries, go to next
item.)

right / wrong
[]  /  [ ]   "SHIRT"
[]  /  [ ]   "SPOON"
[]  /  [ ]   "CHAIR"
[]  /  [ ]   "LAMP"
[]  /  [ ]   "HOUSE"    REPEATING 5 WORDS:

SAY: In one minute, tell me as many animals as you can think of, Ready, GO:
(click to start 60 second clock ->) [] CLOCK

You may click the numbers or use the right arrow to advance the count or the left arrow to reduce it.
  0 []
  1 []        2 []       3 []       4 []         5 []
  6 []        7 []       8 []       9 []       10 []
11 []      12 []     13 []     14 []       15 []
16 []      17 []     18 []     19 []       20 []
21 []      22 []     23 []     24 []       25 []
26 []      27 []     28 []     29 []       30 []
31 []      32 []     33 []     34 []       35 []
36 []      37 []     38 []     39 []     40+ []

CATEGORY FLUENCY 

SAY: "What were the five words I asked you to remember?"

  right / wrong
[]  /  [ ]   "SHIRT"
[]  /  [ ]   "SPOON"
[]  /  [ ]   "CHAIR"
[]  /  [ ]   "LAMP"
[]  /  [ ]   "HOUSE"    REPEATING 5 WORDS: