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Dementia Assessment
Orientation
What is the year?
What is the season?
What day of the week is it?
What is today's date?
What is the month?
What country are we in?
What state are we in?
What city/ town are we in?
Where are we right now or what is the name of the building?
What floor are we on?
Registration
I am going to name 3 objects then repeat them back to me.
Count trials and record
Attention & Calculation
Spell "World" backwards
Recall
Recall the three objects from earlier.
Language
Name two different objects shown in room
Repeat this phrase: "No ifs, ands, or buts"
Patient to follow stage command written on piece of paper. (Close your eyes)
Patient to read & obey
Ask patient to write a complete sentence.
Ask patient to copy a design
Ask which hand is dominant? Then ask pt to take paper in dominant hand.
Fold the paper in half using both hands.
Place the paper on the floor.
Total Score:
Access level of consciousness
Scoring

Mini Mental State Exam Medical Form

Sports Medicine Specialist

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Sunnyvale, CA 94089

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