MINI-COG-TM

Instructions: fill in the 6 digit ID code, follow the directions,
click in four (4) of the circles (right / wrong).

DATE      TIME (24hr)         SITE ID Code:      Partipant ID Code 

1) WORD REPETITION -- GET THE SUBJECT’S ATTENTION, THEN SAY:

“I am going to say three words that I want you to remember. The words are:

              Banana    Sunrise    Chair

Please say them for me now"

(Give the participant 3 tries to repeat the words. If unable after 3 tries, go to next
item. This is not scored.)

2) CLOCK DRAWING –- use blank page.

Hand the subject a pencil/pen and a blank piece of paper.
SAY ALL THE FOLLOWING PHRASES IN THE ORDER:

“Please draw a clock on the paper. Start by drawing a large circle.”

When this is done, say:

“Put all the numbers in the circle.”

When done, say:

“Now set the hands to show 11:10 (that is: 10 past 11).”

If subject has not finished clock drawing in 3 minutes, discontinue and
ask for recall items.

A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:
All numbers 1-12, each only once, are present in the correct order and direction
(clockwise).
Two hands are present, one pointing to 11 and one pointing to 2.

ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED ABNORMAL. REFUSAL TO
DRAW A CLOCK IS SCORED ABNORMAL.

  right / wrong
[]  /  [ ]   CLOCK DRAW

3. RECALL -- SAY: "What were the three words I asked you to remember?"

  right / wrong
[]  /  [ ]   "Banana"
[]  /  [ ]   "Sunrise"
[]  /  [ ]   "Chair"

  -----   Click this box to reset.

Start TIME (24hr):      End TIME (24hr):      Total Time (seconds): 

Mini-CogTM, Copyright S Borson. Licensed for educational use in the
AFA National Memory Screening Day program 2012.
May not be modified or used for other purposes
without permission of the author (soob@uw.edu).
All rights reserved.
Other use restricted.