| Patient Information: | |
| Name: | Diagnosis: |
| Date: | Age: |
| Hospital Record Number: | Sex: |
| | |
| 1. Verbal Fluency: | |
| Animals per 60 seconds. Ask Patient to name as many
animals as they can in 1 minute. | Total Points (1 point/2 animals):
1 2 3 4 5 6 7 8 9 10 |
| 2. Comprehension: (Ask patient to:) | Check if Correct: |
- Point to the ceiling.
- Point to your nose and window.
- Point to your foot, door, and ceiling.
- Point to window, leg, door, and thumb.
| |
| 3. Naming and Word Finding: Parts of Objects | |
- Watch Stem
- Coat lapel
- Watch crystal
- Sole of shoe
- Buckle of Belt
| |
| 4. Orientation | |
| |
| 5. New Learning Ability (4 Unrelated Words) | 5 Minutes | 10 Minutes |
- Brown (Fun) (Grape)
- Honesty (Loyalty) (Happiness)
- Tulip (Carrot) (Stocking)
- Eyedropper (Ankle) (Toothbrush)
| | |
| 6. Verbal Story for Immediate Recall: (Read
the story and then have the patient recall as much as possible) 1 point
for each section correct. |
- It was July/and the Rogers/had packed up
/their four children/in the station wagon/and were off/on vacation.
|
- They were taking/their yearly trip/to the beach/at Gulf Shores.
|
- This year/they were making/a special/one-day stop/at The
Aquarium/in New Orleans.
|
- After a long day's drive/they arrived/at the motel/only to
discover/that in their excitement/they had left/the twins/and
their suitcases/in the front yard.
|
| | |
7. Visual Memory (Hidden Objects)
(Have five
objects with you that you can easily hide such as the ones listed below.
Make sure the patient is observing you as you place each object out of
their view. They get 1 point for each correct response. |
| Object | Found |
| |
| 8. Paired Associate Learing (Read the list
on the left (both words) and then ask the patient to correctly tell you
the associated word that you read beginning with House Read each section
and test separately. A total of 8 points. |
| 1 | 2 |
| a. Weather--Box | a. House--Income |
| b. High--Low | b. Weather--Box |
| c. House--Income | c. Book--Page |
| d. Book--Page | d. High--Low |
| 1 | 2 |
| a. House -- | a. High -- |
| b. High -- | b. House -- |
| c. Weather -- | c. Book -- |
| d. Book -- | d. Weather -- |
9. Constructional Ability
Score: Accuracy, correct orientation, representative (1 point each) |
- Daisy in flower pot
- House in Perspective
| - Score: Correct up to 3 points
- Score: Correct up to 3 points
|
| |
| 10. Written Complex Calculations | |
| a. Addition
108
+79 | b. Subtraction
605
-86 |
| c. Multiplication
108
x36 | d. Division
559/43 |
| Number Correct: 4/4
3/4 2/4
1/4 0/4 | |
| 11.Proverb Interpretation | Score |
| a. Don't cry over spilled milk. | 2 |
| b. Rome wasn't built in a day. | 2 |
| c. A golden hammer can break down an iron
door. | 2 |
| d. The hot coal burns, the cold one blackens. | 2 |
| 12. Similarities | Score: |
| a.
Turnip.............................Cauliflower | 2 |
| b. Car................................Airplane | 2 |
| c. Desk...............................Bookcase | 2 |
| d. Poem..............................Novel | 2 |
| e. Horse..............................Apple | 2 |