MMSE
|
Score |
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What is today’s date? (Then ask for omitted) |
1. Date: |
_________________________ |
______ |
Can you tell me what year it is? |
2. Year: |
_________________________ |
______ |
Can you tell me what month it is? |
3. Month: |
_________________________ |
______ |
Can you tell me what day of the week it is? |
4. Day: |
_________________________ |
______ |
Can you tell me what season it is? |
5. Season: |
_________________________ |
______ |
Can you tell me the name of this building we are in? |
6. Building: |
_________________________ |
______ |
What floor are we on? |
7. Floor: |
_________________________ |
______ |
What city/town are we in? |
8. City: |
_________________________ |
______ |
What county are we in? |
9. County: |
_________________________ |
______ |
What state are we in? |
10. State |
_________________________ |
______ |
May I test your memory? I will say three words and I would |
11. BALL |
_________________________ |
______ |
like you to repeat them after me. |
12. FLAG |
_________________________ |
______ |
(Allow 6 trials. Trial 1 determines score.) |
13. TREE |
_________________________ |
______ |
# TRIALS:_____ Ball:_____ Flag:_____ Tree:_____ |
|
|
|
Now what I would like you to do is start with the number |
14. 93 / D |
_________________________ |
______ |
100 and count backwards by 7s. Go until I say stop. |
15. 86 / L |
_________________________ |
______ |
(If subject cannot do 7s, ask:) |
16. 79 / R |
_________________________ |
______ |
I would like you to try to spell the word “WORLD” |
17. 72 / O |
_________________________ |
______ |
backwards |
18. 65 / W |
_________________________ |
______ |
Can you remember the 3 words I read to you earlier? |
19. BALL |
_________________________ |
______ |
|
20. FLAG |
_________________________ |
______ |
|
21. TREE |
_________________________ |
______ |
(Show subject wrist watch) What is this? |
22. Watch |
_________________________ |
______ |
(Show subject pen/pencil) What is this? |
23. Pen/pencil: |
_________________________ |
______ |
Repeat after me: “No ifs, ands, or buts” |
24. Repeat: |
_________________________ |
______ |
(Hold out blank paper) |
25. R Hand: |
_________________________ |
______ |
Take this piece of paper with your right hand, fold it in half, |
26. Folds: |
_________________________ |
______ |
and put it on the floor |
27: Floor: |
_________________________ |
______ |
Read this and do what it says: CLOSE YOUR EYES |
28. Close eyes: |
_________________________ |
______ |
Write a sentence on this paper. It can be any sentence. |
29. Writing: |
_________________________ |
______ |
Copy this drawing. |
30. Copying: |
_________________________ |
______ |
|
|
TOTAL: |
______ |
CLOSE YOUR EYES
2015 HONOR SCORES 2282015 NICK KORTE HIGHLAND IL
202022 ROUND 2 – JUNIOR HIGHMIDDLE SCHOOL SCORESHEET SCHOOL
22 AUGUST 2011 ROOKIE WEBB SCORES POINTS ON DEBUT
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