Mini Mental State Exam Print

Date: _____________________________

Patient's Name: _____________________________________________

Maximum Score Score ORIENTATION 5 What is the (year) (season) (date) (day) (month)? 5 Where are we: (State) (county) (town or city) (hospital) (floor)? REGISTRATION 3 Name 3 common objects (e.g., "apple, " "table, " "penny"): Take 1 second to say each. Then ask the patient to repeat 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:

ATTENTION AND CALCULATION 5 Spell "world" backwards. The score is the number of letters in correct order. (D___L___R___O___W___). RECALL 3 Ask for the 3 objects repeated above. Give 1 point for each correct answer. (Note: Recall cannot be tested if all 3 objects were not remembered during registration.) LANGUAGE 2 Name a "pencil" and "watch." 1 Repeat the following: "No ifs, ands, or buts." 3 Follow a 3-stage command:
"Take a paper in your right hand, fold it in half and put it on the floor." 1 Read and obey the following: 1 Close your eyes. 1 Write a sentence. 1 Copy the following design: Image f3142_AppendixH.jpg Total Score: _________________________________

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