CONFIRMATION
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Orientation
Score
Maximum
What is the (year) (season) (date) (day) (month)?
( )
5
Where are we (state) (country) (town) (hospital) (floor)?
( )
5
Registration
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. Trials
( )
3
Attention and
Calculation
Serial 7's. 1 point for each correct answer. Stop after 5 answers.
Alternatively, spell "world" backward.
( )
5
Recall
Ask for the 3 objects repeated above. Give 1 point for each correct answer.
( )
3
Language
Name 2 common objects
( )
2
Repeat the following "No ifs, ands, or buts"
( )
1
Follow a 3-stage command: "Take a paper in your hand, fold it in half, and
put it on the chair"
( )
3
Read and obey the following: CLOSE YOUR EYES
( )
1
Write a sentence.
( )
1
Copy the design shown.
( )
1

Total
( )
30