Brief Cognitive Exam

       DATE           TIME (24hr) 

ORIENTATION TO PERSON, TIME, AND PLACE:
right / wrong
   1. Tell me your full name?
   2. How do you spell your last name?
   3. How old are you?
   4. What is your date of birth? (score right only if patient knows day, month, year)
   5. Where were you born? (accept any reasonable answer)
                            PERSON 
right / wrong
   6. What is the date today? (score this item for day of the month, +/-1 day is acceptable)
   7. What is the month?
   8. What is the year?
   9. What is the day of the week?
   10. What season of the year is it?
During March, winter or spring is acceptable; during June, spring or summer is acceptable; during
September, summer, fall, or autumn is acceptable; during December, fall, autumn, or winter is acceptable).
                            TIME 
right / wrong
   11. What is the name or address of this place?
   12. What floor of this building are we on?
   13. What city/town are we in?
   14. What county are we in?
   15. What state are we in?
                            PLACE 

REPETITION:
I am going to name three objects. After I have said them, I want you to
repeat them. Remember what they are because I am going to ask you to name
them again in a few minutes.

The three objects are: "Apple","Table",and"Penny".

Could you please repeat these words for me?
The words should be read at a rate of 1 per second, speaking clearly and audibly.
You are allowed to read the words only once before scoring.

Score on first trial
right / wrong
   16. Apple
   17. Table
   18. Penny          IMMEDIATE RECALL 
Repeat the three words until: 1) the subject correctly repeats all three or
2) 3 total trials have been presented (including initial presentation).

Number of trials: 1    2    3

SPELLING / REVERSE SPELLING:
Now, I am going to give you a word and ask you to spell it forwards and then
backwards. The word is "WORLD." Spell "WORLD" forwards.
If the subject is unable to spell the word, spell it outloud, and ask the subject to repeat the
spelling. Continue until it has been spelled successfully or until you have spelled it to the
subject three times.

right / wrong
   19. Spells World forwards  (score right only if correct on first trial)

Now spell the word "WORLD" backwards:
right / wrong
   20. D
   21. L
   22. R
   23. O
   24. W              "DLROW" TOTAL 
Score 5 points for a correct sequence. Count 1 error for each omission, letter transposition (switching
adjacent letters), insertion (inserting a new letter), or misplacemeent (moving W,O,R,L,D by more than one
space).

RECALL:
Now, what were the 3 objects I asked you to remember?
(This should administered as soon as the "WORLD backwards" item is completed. Cueing is
allowed if the subject is not able to recall words, but credit is not given for any word recalled
after a cue).
right / wrong
   25. Apple
   26. Table
   27. Penny         DELAYED VERBAL RECALL 

LANGUAGE:
Hold up a wrist watch and ask: what is this called? Repeat with a pencil.
right / wrong
   28. WATCH
   29. PENCIL

I would like you to repeat a phrase after me exactly as I say it. The phrase is:
   30. "No ifs, ands, or buts".
It is very important to speak loudly and enunciate clearly as you read this phrase. One repetition of the
phrase is permissible if it is clear that the phrase was not adequately heard. Otherwise, repetition is not
allowed. Accept "no if and or but" if the difficulty is clearly hi-pitch hearing loss.

TOTAL     (BRIEF COGNITIVE EXAMINATION maximum score = 30)

24 - 30   normal, depending on age, education, complaints
20 - 23   mild
10 - 19   moderate
1   -   9   severe
0             profound

TEXT FOR YOUR RECORDS - click here:
- To copy text, highlight text to be copied, then hit "Ctrl-C".
- To paste into your patient's record, position the cursor then hit "Ctrl-V"

Start TIME (24hr):      End TIME (24hr):      Total Time (seconds): 

Electronic form developed at the Palo Alto Veterans Affairs Hospital
  by Wes Ashford, M.D., Ph.D., Anil Sharma, M.D., Jared Tinklenberg, M.D.,
Joy Taylor, Ph.D., Jerome Yesavage, M.D., Javaid Sheikh, M.D.
as part of the MIRECC program.
There is no individual or agency that takes responsibility for the results obtained
with this test or this form.