Date of birth:
Instructions: Read out each question as it is presented on the screen. Unless specified, each question should be asked only once. Make sure that the patient wears glasses and hearing aids if needed, and that there are no interruptions or noises during testing.
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:
42 West Street,
(Allow a maximum of 4 attempts.)
Please mark in all the numbers to indicate the hours of a clock.
Correct spacing required, i.e. even spaces between numbers and 12, 3, 6, and 9? in correct places.
Resource: Download a PDF of a suitable circle
Please mark in hands to show 10 minutes past eleven o’clock. (11.10)
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.
What was the name and address I asked you to remember?
No significant cognitive impairment. Further testing is not necessary.
More information is required. Proceed with informant interview.
Cognitive impairment is indicated. Conduct standard investigations.
What is the date? ...
Please mark in all the numbers to indicate the hours of a clock: ...
Please mark in hands to show 10 minutes past eleven o’clock. (11.10) ...
Can you tell me something that happened in the news recently?: ...
West (St): ...
SAVE & PRINT THIS TEST
Date of birth: