Patient: _________________________ Date: ________________
Folstein MF et al, J Psychiatr Res . 1975; 12:189-98.
ORIENTATION
Ask each of the following questions, and score 1 for each correct answer
1. What is the day of the week

, month

, date

, year

, season

?
2. Where are we? state

, county

, town

, hospital

, floor

.
REGISTRATION
Name 3 objects slowly and clearly: “ apple, penny and table ”. Ask the patient to repeat them. Tell the patient to remember the objects because s/he will be asked to name them in a few minutes.
Score the first try: apple

, penny

, table

.
Repeat objects until all are learned, up to 6 trials.
ATTENTION AND CALCULATION
Ask the patient to perform serial 7 subtraction from 100.
Stop after 5 numbers and score 1 for each number.
If the patient scores less than 5, ask her/him to spell the word “WORLD” backward.
Include the higher of these two scores in final score.
RECALL
Ask the patient to recall the names of the three objects which you asked her/him to repeat above and score 1 for each correct name: apple

, penny

, table

.
LANGUAGE
1. Naming: Point to two objects (e.g., watch and pen) and ask the patient to name them.
Score 1 for each correct name.
2. Repetition: Ask the patient to repeat, “No ifs, ands or buts.” Allow only one trial..
3. Three-stage command: Ask the patient to “Take a paper in your right hand, fold it in half, and put it on the floor.” Score 1 for each part correctly executed.
4. Reading: Point to the phrase “CLOSE YOUR EYES” on page 2. Ask the patient to read the sentence to do what it says. Score 1 if eyes are closed.
5. Writing: Ask the patient to write a sentence on page 2. Do not dictate a sentence. The sentence must contain a patient and verb, and must make sense. Correct spelling and punctuation are not necessary. Score 0 or 1.
6. Copying: Ask the patient to copy the figure on the page 2 exactly. All 10 angles and intersections must be present to score 1.
TOTAL:
__ /3
__ /5
__ /5
__ /3
__ /5
__ /5
__ /1
__ /1
__ /2
__ /1
__ /3
__ /1
_____
__ __ / __ __ score serial 7’s, unless patient refuses or is unable to answer

Patient: _________________________ Date: ________________
Write sentence here:
Copy the figure:

Patient: _________________________ Date: ________________
DIRECTIONS
1. State, “I’m going to ask you to draw a clock on this sheet of paper.” Hand the patient a copy of the CDT form.
2. “Please draw a clock and set the time to 11:10. Include the numbers and hands.”
3. Do not provide a pre-drawn clock. You may remind the patient of the desired time if required.
4. Scoring: If the clock is grossly intact (numbers and hands in generally correct positions, hands of different lengths), score 1. Otherwise, score 0.
Score: ____
DIRECTIONS
1. State, “I would like to name as many animals as you can think of in one minute. I will tell you when to start and stop. Do you understand the directions?”
2. Tell the patient to start naming animals. Write down the animal names below in the order stated.
Any kind of animal is acceptable. Write down repeated animals, but do not score those. After one minute, tell the patient to stop.
3. Scoring: Count each unique animal listed.
List of Animals:
Score: ___

Patient: _________________________
Date: ________________