L-Cog

Jeff Baker, Ph.D. - Chief Psychologist (APC) - (409) 747-2250

          Patient Initials:
Patients Birthyear:
Ethnicity:                                 Gender:          Age:         Exam Site:

Today’s Date :

Score items 1-3: 3 – spontaneous correct response; 2 – correct response with logical cue; 1 - correct response with multiple choice; 0 – unable to generate response
1. What is today's Date? ____________________________
2. What time is it right now? _______________________________
3. What is the name of this place? _________________________
4. I am going to read a name and address to you. When I finish I would like you to repeat the name and address back to me. This is not a person that you know. This is a check on your memory. (indicate which item was given, alternate items for serial administrations). a. Monday – John Brown, 42 Market Street, Chicago b. Tuesday – Tim Smith, 84 Center Ave., Cleveland c. Wednesday – Sally Jones, 23 North Boulevard, Seattle d. Thursday – Bill Jackson, 16 Maple Court, Houston e. Friday – Judy Wilson, 75 Ocean Ave., Baltimore f. Saturday – Bob Taylor, 27 Main Street, Los Angeles g. Sunday – Susan Anderson, 58 River Road, Atlanta
Score: 3 – 3 accurate repetitions; 2 – 2 accurate repetitions; 1 – 1 correct repetition; 0 – No correct repetitions
5. I would like you to count backward from 20 to 1 (give example 20, 19, 18 if necessary). Score: 3 – without error; 2 – one error; 1 - two errors; 0 – more than two errors
6. Please say the months of the year in reverse order beginning with December (example: December, November). Score: 3 – without error; 2 – one error; 1 - two errors; 0 – more than two errors
7. I would like you to estimate when 30 seconds has passed. That is half a minute. I will say “go” and you are to say “stop” when 30 seconds have passed. After saying go say: Tell me when 30 seconds has passed.
Score: 3 – 25-35 secs; 2 – 20-24 or 36-40 secs; 1 –15-19 or 41-45 secs; 0 – < 15 seconds or > 45 secs
8. Please watch what I do with my hand. Notice the sequence of movements, beginning with this one (demonstrate fist, edge, palm for 2 seconds each). I’m going to do that again, so watch carefully (demonstrate a second time). Now you try that.
Score: 3 – 3 correct repetitions; 2 – 2 correct repetitions; 1 – 1 correct repetition; 0 – no correct repetitions
9. When I say the word “red” I want you to raise your finger like this (demonstrate). Then you can put it down (demonstrate). When I say “green” don’t do anything (demonstrate holding fist in a closed position). (Order of presentation: RED—GREEN—GREEN—RED—GREEN—RED)
Score: 3 – correct response on all 6 trials; 2 – correct response on 4 or 5 trials; 1 – correct response on 3 or fewer trials; 0 – if correct on no trial.
10. Do you remember the name and address I read to you earlier? I want you to recall that information now.
Score: 3 – full, accurate recall; 2 – partial spontaneous recall; 1 – if any further information is recalled after the name of the person is provided as prompt; 0 – unable to recall

TOTAL SCORE __ / 30
Total Score
23-30 Normal (Elder Population) 18-22 Memory Impairment <18 Severe Memory Impairment