Patient___________________________________ Examiner ____________________________ Date____________
Maximum Score: ____________
Table of Contents
Orientation
5 ( ) What is the (year) (season) (date) (day) (month)?
5 ( ) Where are we (state) (country) (town) (hospital) (floor)?
Registration
3 ( ) Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record.
Attention and Calculation
5 ( ) Serial 7’s. 1 point for each correct answer. Stop after 5 answers. Alternatively, spell “world” backward.
Recall
3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer.
Language
2 ( ) Name a pencil and watch.
1 ( ) Repeat the following “No ifs, ands, or buts”
3 ( ) Follow a 3-stage command: “Take a paper in your hand, fold it in half, and put it on the floor.”
1 ( ) Read and obey the following: CLOSE YOUR EYES
1 ( ) Write a sentence.
1 ( ) Copy the design shown.
Total Score: __________
ASSESS level of consciousness along a continuum: Alert – Drowsy – Stupor – Coma