PATIENT NAME: _______________________________

       DATE:           TIME (24hr): 

Enter birthdate (mm): Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    (dd):    (yyyy):
Sex:  []Male    []Female                Enter education (years):
Race: []Caucasian []Black []Hispanic []Asian []Other

"Please repeat these three words: "BALL",   "FLAG",  "TREE"..

"So that you will remember these words, repeat them again."
(prompt missed words)

1.  What is today's date?  Correct:[];  within 5 days:[]; > 5 days off:[]

2.  Name as many animals as you can, GO: (stop after 30 seconds)

0 []  1 []      2 []     3 []      4 []      5 []      6 []     7 []    8 []
            9 []    10 []  11 []    12 []    13 []    14 []  15 []  16 []
          17 []    18 []  19 []    20 []    21 []    22 []  23 []  + []   

3.  What were the 3 words that I asked you to repeat? (click if recalled correctly)
                        wrong   correct
         "BALL"    []      []                 (date:  correct = 4, close = 2)
         "FLAG"    []      []                 (total = date + 2/3*animals + 3*recall)
         "TREE"    []      []                                          TOTAL SCORE: 

SCORING:   0    -  11   =  FURTHER DEMENTIA EVALUATION
                      12  -  18   =  ASK ADDITIONAL QUESTIONS
                      19  -         =  DEMENTIA UNLIKELY

SUGGESTED ADDITIONAL SCREENING QUESTIONS:

•     Spell "WORLD" backwards (each error is additional concern)
•     Draw a clock showing 8:20  (note numbering and hand placement)
•     Have you been depressed lately?  ________(consider depression)
•     Have you had difficulty with your memory ? ________________
•     Have you had problems sleeping recently? ________________

 (HTML scripted by Ashford,JW, copyright 2002, revised 6/15; palm-pilot version available)