Alzheimer's Foundation of America Memory Screening Test - UK Version
This test is derived from 2 tests, the MINI-Cog and GP-Cog
This test is designed for testing memory testing items and visuo-spatial orientation (09/19/2013).
Instructions: fill in the Site ID code and Participant ID code (4 digits each),
then follow the directions,
click in the circles to indicate responses (e.g., correct / incorrect).
DATE
TIME (24hr)
SITE ID Code:
Partipant ID Code
Unless specified, each question should only be asked once.
Name and Address for subsequent recall test
1. ?I am going to give you a name and address. After I have said it, I want you to repeat it.
Remember this name and address because I am going to ask you to tell it to me again in
a few minutes: John Brown, 42 Market Street, Chicago.? (Allow a maximum of 4 attempts).
Time Orientation
Correct Incorrect
2. "What is the date?" (exact only)
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CLOCK DRAWING ?- use blank page.
Hand the subject a pencil/pen and a blank piece of paper.
SAY ALL THE FOLLOWING PHRASES IN THE ORDER:
?Please draw a clock on the paper. Start by drawing a large circle.?
When this is done, say:
3. "Please mark in all the numbers to indicate
the hours of a clock" (correct spacing required)
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4. "Please mark in hands to show 10 minutes past
eleven o'clock (11:10)"
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A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:
All numbers 1-12, each only once, are present in the correct order and direction
(clockwise).
Two hands are present, one pointing to 11 and one pointing to 2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED ABNORMAL. REFUSAL TO
DRAW A CLOCK IS SCORED ABNORMAL.
Correct Incorrect
CLOCK DRAW NORMAL
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Information
5. "Can you tell me something that happened in the news recently?"
(Recently = in the last week. If a general answer is given, e.g.
"war", "lot of rain", ask for details. Only specific answer scores).
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RECALL:
6. "What was the name and address I asked you to remember."
Correct / Incorrect
John
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Brown
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42
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Market (St)
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Chicago
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Start TIME (24hr):
End TIME (24hr):
Total Time (seconds):