The Galveston Orientation and Amnesia Test
Harvey S. Levin, Ph.D., Vincent M. O'Donnell, M.A.,
& Robert G. Grossman, M.D.
Instructions: Can be administered Daily. Score of 78 or more on three consecutive occasions is considered to indicate that patient is out of post-traumatic amnesia (PTA).
| Question | Error Score |
Notes |
| What is your name? | -2 _____ | Must give both first name and surname. |
| When were you born? | -4 _____ | Must give day, month, and year. |
| Where do you live? | -4 _____ | Town is sufficient. |
| Where are you now: | ||
| (a) City | -5 _____ | Must give actual town. |
| (b) Building | -5 _____ | Usually in hospital or rehab center. Actual name necessary. |
| When were you admitted to this hospital? | -5 _____ | Date. |
| How did you get here? | -5 _____ | Mode of transport. |
| What is the first event you can remember after the injury? | -5 _____ | Any plausible event is sufficient (record answer) |
| Can you give some detail? | -5 _____ | Must give relevant detail. |
| Can you describe the last event you can recall before the accident? | -5 _____ | Any plausible event is sufficient (record answer) |
| What time is it now? | -5 _____ | -1 for each half-hour error. |
| What day of the week is it? | -3 _____ | -1 for each day error. |
| What day of the month is it? (i.e. the date) | -5 _____ | -1 for each day error. |
| What is the month? | -15 _____ | -5 for each month error. |
| What is the year? | -30 _____ | -10 for each year error. |
Total Error: |
||
| Total Actual Score = (100 - total error) = 100 - _____ = | Can be a negative number. | |
| 76-100 = Normal / 66-75 = Borderline / <66 = Impaired | ||
| Developed by Harvey Levin, Ph.D., Vincent M. O'Donnell, M.A., & Robert G. Grossman, M.D. |
| 100 | ||||||||||||||
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| 0 | ||||||||||||||
| Date | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ | ____ |