FormDownload Logo
Powered By: FormSwift Lease Agreement

Free Mini-Mental State Examination Form

Forms in Medical

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.

 Advertisements

Mini-Mental State Examination Form

Text Version of this Form

MINI-MENTAL STATE EXAMINATION

Resident: Date:

Examiner’s Name:

Resident Maximum

Score Score
ORIENTATION

5 What is the (year), (season), (date), (day), (month)?

5 Where are we (country), (state), (county), (city), (clinic)?

REGISTRATION

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
Trials:
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
resident’s spelling:

RECALL
3 Ask the resident to repeat the objects above (see Registration). Give one
point for each correct answer.
LANGUAGE

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

 

 

COPY DESIGN


 Advertisements

Review Mini-Mental State Examination Form

Name
Email
Review Title
Rating
Review Content

Mini-Mental State Examination Form Reviews