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MINI MENTAL STATE EXAM
ADMINISTRATIVE INFORMATION
0a. Completion Date: / / 0b. Staff ID:
Month Day Year
Materials: Black pen, pencil, wrist watch, one sheet of paper, pentagons and “Close your eyes” card
“In this next part of the exam I will ask you some questions and give you some short tasks that will require memory and concentration. Some may be a little bit more difficult than others.”
Correct (^) Don’t knowIncorrect / Attempted/Not Refused
0c. What is your full name? 1 0 0
0d. How old are you? 1 0 0
0e. What is the full date of your birth? 1 0 0
0f. Without looking at a clock or watch, what is the approximate time of day?
Score as correct, if within one hour of the actual time.
ID NUMBER: FORM CODE:^ M^ M^ E^
DATE: 09/27/ Version 3.
Scoring note:
Items which are not attempted due to a physical disability (e.g., vision or hearing loss) should be marked as “Not Attempted.”
Items which are not administered due to cognitive impairment should be marked as “Incorrect.”
Correct
Incorrect / Don’t know
Not Attempted / Refused
- What year is this? 1 0 0
- What season is this? 1 0 0
- What month is this?
Score as correct, if within one day of the actual month.
- What is the day of the week?
If the participant gives the date instead of the day, give credit for date if correct, and say: “Good, and what day of the week is it?”
- What is the date? 1 0 0
- What state are we in? 1 0 0
- What city is this? 1 0 0
- What county do you live in? 1 0 0
- What is the name of this place where we are right now?
Prompt for more detail, if a generic or vague response is given.
- Are we on the ground floor or a higher floor of this building?
Winter: Dec., Jan., Feb., March Spring: March, April, May, June Summer: June, July, August, Sept. Fall/Autumn: Sept., Oct., Nov., Dec.
Correct
Incorrect / Don’t Know
Not Attempted / Refused
- Here is a drawing. Please copy the drawing on
this piece of paper.
Hand the participant a piece of paper and the pentagons card. Orient the card as shown. Allow 1 minute for copying. Score 1 if all sides and angles are preserved and two five-sided figures intersect to form a four-sided figure. Ignore tremor, rotation, minor gaps, and self-correction. Note dominant hand used.
Now, what were those three objects I asked you to remember? Provide no hints.
Correct
Incorrect / Don’t Know
Not Attempted / Refused
- Apple 1 0 0
- Penny 1 0 0
- Table 1 0 0
Listen carefully because I'm going to ask you to do something. Hold up a piece of paper in plain view of the participant but out of reach. Take this paper in your <non-dominant > hand (pause) , fold it in half (pause) , and put it on the floor (substitute “ Hand it back to me ,” if participant is disabled or bed- bound). After saying the entire command, hold the paper within reach of the participant (but not in favor of either hand). Do not repeat any individual part of the command. One repetition is permitted at the participant’s request, but the entire command must be repeated verbatim. If the participant reaches for the paper immediately after hearing the first portion of the command, move your hand away so that the paper is out of reach and continue to state the next two parts of the command without interruption.
Correct
Incorrect / Don’t Know
Not Attempted / Refused
- Takes paper in correct hand 1 0 0
- Folds paper in half 1 0 0
- Places paper on the floor 1 0 0
Please read this sentence out loud and then do what it says. Display sentence command “CLOSE YOUR EYES.” Score 1 point only if the participant closes his/her eyes. As soon as the participant closes his/her eyes, say, “ Open.”
Correct
Incorrect / Don’t Know
Not Attempted / Refused
- Closes eyes 1 0 0
- MMSE Total Score (CDART will calculate the score):
- How many questions were not attempted due to EITHER refusal or physical disability? (Consider only Q1 to Q30. If all Q1-Q30 are answered, enter 0.)
