Mini Mental Status

A. Orientation 

(Maximum Score 10 Points)

1.       Time (Maximum Score 5 Points)

          A.  Year        ________     D.  Day         ________

          B.  Month      ________     E.  Season    ________

          C.  Date        ________

2.       Place

          A.  State       ________    D.  Hospital   ________

          B.  County    ________    E.  Floor/Clinic ________

          C.  Town       ________

B. Registration

(Maximum Score 3 Points)

Name 3 objects (hat, car, tree).

Repeat until the patient learns all 3.

         
Hat     _________

Car     _________

Tree   _________

Number of Trials     _________

C. Attention and Calculations

(Maximum Score 5 Points)

1.       Serial 7’s.  Stop after 5 correct answers
(100 – 7 =  93; -7 = 86; -7 = 79; -7 = 65)  ____________

          OR

2.       Spell “WORLD” forwards.  If able to complete, spell “WORLD” backwards.

          (One point for each correct letter, when spelled backwards)
           ____________

D. Recall

(Maximum Score 3 Points)

Ask for the 3 objects in Section B.          ________

E. Language

(Maximum Score 9 Points)

1.       Name the objects: (One point for each word)
Watch _________   Pencil _________

2.       Repeat the phrase “No Ifs, Ands, or Buts” _________

3.       Follow a 3-stage command: Take a piece of paper in your right hand, fold it in half and place it on the floor _________ (3 points)

4.       Read and do the following: Close your eyes _________

5.       Write a sentence (grammar and punctuation are not important)
________________________________________________
________________________________________________

6.       Copy the design (This section is not scored)

7.       Draw the face of a clock (This section is not scored)