"Mini-Mental State Examination Form"

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MINI-MENTAL STATE EXAMINATION
Resident:
Date:
Examiner's Name:
Resident
Maximum
Score
Score
ORIENTATION
5
What is the (year),
(season),
(date),
(day),
(month)?
5
Where are we (country),
(state),
(county),
(city),
(clinic)?
REGISTRATION
3
Name 3 objects allotting one second to say each one. Then ask the resident to
name all 3 objects after you have said them. Give one point for each correct
answer. Repeat them until he/ she hears all 3. Count trials and record number.
APPLE
BOOK
COAT
Trials:
ATTENTION AND CALCULATION
Begin with 100 and count back by 7 (stop after 5 answers) 93, 86, 79, 72, 65.
5
Score one point for each correct answer. If the resident will not perform this
task, ask the resident to spell "WORLD" backwards (DLROW). Record the
resident’s spelling:
RECALL
3
Ask the resident to repeat the objects above (see Registration). Give one
point for each correct answer.
LANGUAGE
2
Naming: Show a pencil, and a watch and ask the resident to name them.
1
Repetition: Repeat the following: "No ifs, ands or buts."
3
Three Stage Command: Follow the three-stage command. "Take paper in
your right hand; fold it in half; and put it on the table."
1
Reading: Read and obey the following: "Close your eyes." Show the resident
the item written on the reverse side, or attached.
1
Writing: Write a sentence (on reverse side)
1
Copying: Copy the design of the intersecting pentagons (on reverse side).
30
Total Score Possible
MINI-MENTAL STATE EXAMINATION
Resident:
Date:
Examiner's Name:
Resident
Maximum
Score
Score
ORIENTATION
5
What is the (year),
(season),
(date),
(day),
(month)?
5
Where are we (country),
(state),
(county),
(city),
(clinic)?
REGISTRATION
3
Name 3 objects allotting one second to say each one. Then ask the resident to
name all 3 objects after you have said them. Give one point for each correct
answer. Repeat them until he/ she hears all 3. Count trials and record number.
APPLE
BOOK
COAT
Trials:
ATTENTION AND CALCULATION
Begin with 100 and count back by 7 (stop after 5 answers) 93, 86, 79, 72, 65.
5
Score one point for each correct answer. If the resident will not perform this
task, ask the resident to spell "WORLD" backwards (DLROW). Record the
resident’s spelling:
RECALL
3
Ask the resident to repeat the objects above (see Registration). Give one
point for each correct answer.
LANGUAGE
2
Naming: Show a pencil, and a watch and ask the resident to name them.
1
Repetition: Repeat the following: "No ifs, ands or buts."
3
Three Stage Command: Follow the three-stage command. "Take paper in
your right hand; fold it in half; and put it on the table."
1
Reading: Read and obey the following: "Close your eyes." Show the resident
the item written on the reverse side, or attached.
1
Writing: Write a sentence (on reverse side)
1
Copying: Copy the design of the intersecting pentagons (on reverse side).
30
Total Score Possible
CLOSE YOUR EYES
WRITE A SENTENCE
COPY DESIGN
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