Patient's name____________________________________
Assessor's name____________________________Date__________

Folstein Mini-Mental Status Examination  (max 30, <26=concern, <24=further assessment)
Orientation         Score (max 10)
·  What is today's date?       _____
·  What is the year?       _____
·  What is the month?       _____
·  What day is today?       _____
·  What season is it?       _____
·  What building are we in?      _____
·  What floor are we on?       _____
·  What town are we in?       _____
·  What province are we in?      _____
·  What country are we in?       _____

Registration         Score (max 3)
·  "ball","flag","tree"; ask to repeat. First     _____
  repetition is score. Repeat until get
  right or 6 times.

 Attention & calculation
 Score (max 5)
 · 100-7's for 5 subtractions      _____
 OR
 · spell "world" backwards with 1 for each letter
  in exactly the right place

 Recall         Score (max 3)
 · 3 previous words (from Registration)     _____

 Language        Score(max 9)
 · Name a watch and a pencil (2 points)     _____
 · Repeat the following "no ifs, ands or buts" (1 point)             _____
 · Follow a three stage command: "take the paper in
    your right hand, fold it in half and put it on the
    floor" (3 points)       _____
 · Repeat and obey the following CLOSE YOUR EYES (1 point)  _____
 · "Write a sentence"; must have noun, verb and be
    sensible (1 point)       _____
 · Draw 2 intersecting pentagons each side 1". Must
    have 10 angles and intersect (1 point)     _____