Free Printable Mini-Mental State Examination Form
For the Mental State Examination of your patients you may use the Questionnaire in this document. You may print this form AS it is and give it to your patients for examining their Mental State.
Text Version of this Form
MINI-MENTAL STATE EXAMINATION
5 What is the (year), (season), (date), (day), (month)?
5 Where are we (country), (state), (county), (city), (clinic)?
3 Name 3 objects allotting one second to say each one. Then ask the resident to
name all 3 objects after you have said them. Give one point for each correct
answer. Repeat them until he/ she hears all 3. Count trials and record number.
APPLE BOOK COAT
ATTENTION AND CALCULATION
5 Begin with 100 and count back by 7 (stop after 5 answers) 93, 86, 79, 72, 65.
Score one point for each correct answer. If the resident will not perform this
task, ask the resident to spell “WORLD” backwards (DLROW). Record the
3 Ask the resident to repeat the objects above (see Registration). Give one
point for each correct answer.
2 Naming: Show a pencil, and a watch and ask the resident to name them.
1 Repetition: Repeat the following: “No ifs, ands or buts.”
3 Three Stage Command: Follow the three-stage command. “Take paper in
your right hand; fold it in half; and put it on the table.”
1 Reading: Read and obey the following: “Close your eyes.” Show the resident
the item written on the reverse side, or attached.
1 Writing: Write a sentence (on reverse side)
1 Copying: Copy the design of the intersecting pentagons (on reverse side).
30 Total Score Possible
CLOSE YOUR EYES
WRITE A SENTENCE
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