CLIENT’S NAME:
DATE(S) OF ADMINISTRATION:
ADAPTED YES/NO TEST
ORIENTATION IN RECOGNITION FORMAT
Comments:
I. Orientation to Person
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Is your name Smith?
Do you live in Jamaica Plain?
Do you live on
Dr (St)?
Is you last name
?
Are you 22 years old?
Is your first name John/Susan?
Are you
years old?
Do you live in
(city)?
Is your first name
?
Do you live on Boylston Street?
II. Orientation to Place
1. Are we in a bank?
2. Are the lights on in this room?
3. Are you lying/sitting on a bed?
4. Are we in a Speech Clinic?
5. Is this Calvin College Speech Therapy Clinic?
6. Is it dark in this room?
7. Are you sitting in a chair/wheelchair?
8. Is this Cambridge City Hospital?
9. Have you been here for
week(s)?
10. Have you been here for a month?
III. Orientation to Time
1. Is it morning?
2. Is it spring/summer?
3. Is it the month of January?
4. Is it afternoon?
5. Is it the month of
?
6. Is it winter/fall?
7. Is it the weekend?
8. Have you eaten breakfast/lunch?
9. Is it a weekday?
10. Have you eaten dinner?
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO