Draw CLOCK (Ten past eleven)Examiner points (0–3)Undo strokeClear drawingCompleted on paperContourNumbersHands
MemoryRead list of words, subject must repeat them. Do 2 trials, even if 1st trial is successful. Do a recall after 5 minutes.First memory trial: words repeatedSecond memory trial: words repeatedTrialFACEVELVETCHURCHDAISYRED1st trial2nd trialNo points.
Attention: digitsExaminer points (0–2)Read list of digits (1 digit / sec.).Forward order: 2 1 8 5 4Subject’s forward responseForward order correctBackward order: 7 4 2Subject’s backward responseBackward order correct
Attention: letter tappingExaminer points (0–1)Read list of letters. The subject must tap with his hand at each letter A. No points if ≥ 2 errors.Number of errors
Serial 7 subtraction starting at 100Examiner points (0–3)9386797265Subject’s subtraction responses4 or 5 correct subtractions: 3 pts; 2 or 3 correct: 2 pts; 1 correct: 1 pt; 0 correct: 0.
Language: repetitionExaminer points (0–2)I only know that John is the one to help today.First sentence: responseFirst sentence correctThe cat always hid under the couch when dogs were in the room.Second sentence: responseSecond sentence correct
Language: fluencyExaminer points (0–1)Name maximum number of words in one minute that begin with the letter F.Number of wordsWordsN ≥ 11 words.
AbstractionExaminer points (0–2)Similarity between e.g. orange - banana = fruitTrain - bicycle: subject’s responseWatch - ruler: subject’s responseTrain - bicycle correctWatch - ruler correct
Delayed recallExaminer points (0–5)Has to recall words WITH NO CUE. Points for UNCUED recall only.Words recalledResponse levelFACEVELVETCHURCHDAISYREDUncued (×3)Category cue (×2)Multiple choice cue (×1)Not recalledMemory Index Score (MIS), /15
OrientationExaminer points (0–6)Date: subject’s responseCorrectMonth: subject’s responseCorrectYear: subject’s responseCorrectDay: subject’s responseCorrectPlace: subject’s responseCorrectCity: subject’s responseCorrect
Staff scoring — complete after returnFor the front desk or doctor to complete after reviewing the returned worksheet.Total score, /30MIS, /15Education adjustment applied: add 1 point if ≤ 12 years educationSource form reference: Normal ≥ 26/30.Assessment notes