Free Mini-Mental State Examination Form - PDF Form Download
The Mini-Mental State Examination template provides the guidelines to access the mental condition of the resident. The Mini-Mental State Examination template has five sections to determine the perceptual stability. Maximum rating of 30 points is feasible when the respondent attempts to solve them meticulously and sanely.
However, the bifurcation of these points in various sections and subsection comes with definitive guidelines for the actions and the distribution of them. Furthermore, the template clearly indicates the division of points and their allocation on successful completion of the assignment.
These questions need participation of the resident on mental, logical, and physical levels. The examiner can analyze the responses from the resident on unparalleled and unbiased platform and record the points earned from responses as well as responses when applicable.
- The resident is required to attempt answering all questions.
- The examiner is required to classify the response and mark points based upon the guidelines mentioned in each question. The maximum permissible points are 30.
- There are no common to apply rules while marking points and the examiner must compute points earned by the respondent on responses recorded versus the directives to allocate the points.
- Providing the material to complete the test is necessary.
- Keen observation of the examiner is of paramount essence while conducting the Mini-Mental State Examination.
Begin by typing the name of the resident, followed by the date, and then the name of the examiner. Enter score rating for the resident in the spaces provided prior to each section and subsection. Proceed by asking questions from the Orientation section about the year, season, date, day, month and country, state, county, city, and clinic. Both questions carry five points each and are decisive during the computation of the overall rating.
Continue with the Registration section and record the number of trials required for a correct response in repeating the three objects.
The next section Attention and Calculation requires recording the response and/or spelling by the resident when asked to spell word WORLD backwards.
Mark your ratings out of three in the Recall section of the Mini-Mental State Examination.
Enter the score of the resident in the next section Language. You can rate up to two for this section. Mark your rating accordingly.
Add 1 point in section Repetition when the resident repeats rightly after the examiner.
Three Stage Command subsection has scope to offer up to three points upon the successful completion of the task. Record your reading and add points as applicable. Maximum permissible points in this subsection are 3.
Reading subsection comes with one maximum permissible point. Show the resident the text, mark your reading, and rate accordingly.
Ask the resident to write a sentence and rate up to one point for successful completion of the task.
Copying the pentagon attracts one point upon the successful completion of the task. Give ratings of up to one point based on the performance of the resident.
Provide page number 2 as it is on the reverse of the Mini-Mental State Examination.
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