Today's date: Time:
Patient's Initials: Patient Number:
Study Number: Rater's Initials:
Severe Impairment Battery
1. A. Hello, my name is ... Spontaneously shakes hands Raises right hand toward examiner, does not take hand No response or incorrect
B. Come with me ... 1 2 3
Alternative: Can you sit up... 4
C. Please sit here.... 1 2 3
Alternative: Come and sit by this table... 4
2. My name is ... 1 2 3
3. What's your name? 1 2 3
4. A) Write your name.... 1 2 3
B.) Can you copy this? 1 2 3
5. What month is it now? 1 2 3
6. Months of the year.... ? 1 2 3
7. Name of this city? 1 2 3
8. A) What do you call (cup/mug)? 1 2 3
B) What do you call (spoon)? 1 2 3
9. A) Read this card (give me your hand) 1 2 3
B) Give me other hand... 1 2 3
C) What does this say? 1 2 3
10. Pardon me, what did you say? 1 2 3
11.A) People spend money.... 1 2 3
B) Baby ..... 1 2 3
12. Now say this: 2, 5, 87, 41, 582, 694, 6439, 7286, 42731, 75836
correct repetition of a 3, 4, or 5 digit series
correct repetition of a 1 or 2 digit series
no response or incorrect
13. All the things you like to eat/cook.... 1 2 3
14. Do you remember my name? 1 2 3
15. What's this? (photo of cup)..... 1 2 3
16. How would you use it? (cup) 1
17. Take hold of this(cup); What is it?
18. Show me again how you would use it.
19. Is this a hat or a cup?
20. What's this ? (photo of spoon)
21. How would you use this ?( spoon)
22. Take hold of this( spoon) What is it?
23. Show me again how you use (spoon).
24. Is it a boot or a spoon?
25. Spoon on mat with distractors.....
cup and spoon named
either cup or spoon named
26. What color is this? (blue)
27. Which of these blocks is the same color as ...
28. Change order of blocks....
29. Give me a different block....
30.A) What color is this? (red)
B) What color is this? (green)
C) What shape is this? (square)
31. This is my square block; show me yours.....
32. Change order of blocks.....
33. Show me a different shape...
34. A) What shape is this? (round)
B) What shape is this? (triangle)
35. A) Draw a circle....
B)Draw a square....
36. Count number of table taps.....
37. Holding up and counting fingers...
38. Cup & spoon on mat with distractors....
39. Call pt's name while leaving...
40. How've you been? Any plans?