Enter birthdate (mm):    (dd):    (yyyy):
Sex:   []Male   [] Female           Enter education (years):              
Race:  []Caucasian   []Black   []Hispanic   []Asian     []Other

     right / wrong
Orientation Questions:  Ask the following questions:
   []      []    x1.    What is your last name?
   []      []    x2.    What is your first name?
   []      []    x3.    What is your birthday?
   []      []    x4.    What is your birth year?
   []      []    x5.    How old are you?
   []      []    x6.    In what county/city were you born?
   []      []    x7.    In what state (country if not US) were you born?
   []      []    x8.    What is your mother's maiden name?
   []      []    x9.    How far did you go in school (years of education)?
   []      []    x10.  What is your address (or phone number)?                   PERSON
   []      []    1.       What is today's date?
   []      []    2.       What is the month?
   []      []    3.       What is the year?
   []      []    4.       What day of the week is today?
   []      []    5.       What season is it?                                                            DATE
   []      []    6.       What is the name of this clinic (place)?
   []      []    7.       What floor are we on?
   []      []    8.       What city are we in?   
   []      []    9.       What county are we in?
   []      []   10.     What state are we in?                                                    PLACE

PRESIDENTS
   []      []    x11.    Who is the President of the US?
   []      []    x12.    Who was the President before him?
   []      []    x13.    Who was the President before him?
   []      []    x14.    Who was the first President of the US?
   []      []    x15.    Name another US President?                           PRESIDENTS:

IMMEDIATE RECALL:  Ask the subject if you may test his/her memory.    Then say "ball", "flag", "tree" clearly and slowly, about 1 second for each. After you have said all 3 words, ask him/her to repeat them.  The first repetition determines the score (0-3), but keep saying  them until he/she can repeat all 3, up to 6 tries.  If he/she does  not eventually learn all 3, recall cannot be meaningfully tested:
   []     []    11.  BALL
   []     []    12.  FLAG
   []     []    13.  TREE            Note # trials:          IMMEDIATE RECALL:

ATTENTION
A) Ask the subject to begin with 100 and count backwards by 7. Stop after 5 subtractions.  Score the correct subtractions.
   []    []    14.  "93"
   []    []    15.  "86"
   []    []    16.  "79"
   []    []    17.  "72"
   []    []    18.  "65"         SERIAL 7's    TOTAL:

B) Ask the subject to spell the word "WORLD"  backwards. The score is the number of letters in correct position. For example, "DLROW" is 5,  "DLORW" is 3, "LROWD" is 0.
   []    []    19.  "D"
   []    []    20.  "L"
   []    []    21.  "R"
   []    []    22.  "O"
   []    []    23.  "W"          "DLROW"   TOTAL:        Greater score of A or B:

DELAYED VERBAL RECALL:  Ask the subject to recall the 3 words you previously asked him/her to remember.
   []   []    24.  BALL?
   []   []    25.  FLAG?
   []   []    26.  TREE?                                  DELAYED VERBAL RECALL: 

NAMING: Show the subject a wrist watch and ask him/her what it is. Repeat for pencil.
   []   []    27.  WATCH
   []   []    28.  PENCIL

REPETITION: Ask subject to repeat: "No ifs, ands, or buts" (accept "no if and or but")  
   []   []    29.  REPETITION

3-STAGE COMMAND: Give the subject a plain  piece of paper and say, "Take the paper in your hand, fold it in half, and put it on the floor."
   []   []    30.  TAKES
   []   []    31.  FOLDS
   []   []    32.  PUTS

READING: Hold up the card reading, "Close your eyes", so the subject can see it clearly. Ask him/her to read it and do what it says. Score correctly only if the subject actually closes his/her eyes.
   []    []    33.  CLOSES EYES

WRITING: Give subject a piece of paper and ask him/her to write a sentence. It is to be written spontaneously.  It must contain a subject and verb and be sensible.   Correct grammar and punctuation are not necessary.
   []    []    34.  SENTENCE                                                      LANGUAGE:

COPYING: Ask subject to draw intersecting pentagons
   []    []    35.  PENTAGONS                                                                            

click to calculate:(click):        (MMSE maximum score = 30)

TOTAL MMSE (s7s):          MMSE (dlrow):            MMSE (max):

TOTAL MMSE WITH EXTENSION:   (maximum score = 50; normal > 40) 

NAME AS MANY ANIMALS AS YOU CAN IN 1 MINUTE:

          1st 15s                     2nd 15s                      3rd 15s                      4th 15s

    1  ______             ______                ______               ______
    2  ______             ______                ______               ______
    3  ______             ______                ______               ______
    4  ______             ______                ______               ______
    5  ______             ______                ______               ______
    6  ______             ______                ______               ______
    7  ______             ______                ______               ______
    8  ______             ______                ______               ______
    9  ______             ______                ______               ______
    10______             ______                ______               ______
    11______             ______                ______               ______
    12______             ______                ______               ______
    13______             ______                ______               ______
    14______             ______                ______               ______
    15______             ______                ______               ______

            (expect normal elderly to name at least 15)             TOTAL______

(when completed, you may print out form for your records)