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