Standardized Mini-Mental State Examination Form
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1
2STANDARDIZED MINI-MENTAL STATE EXAMINATION (SMMSE)
QUESTION
TIME ALLOWED
SCORE
1
a.
What year is this?
10 seconds
/1
b.
Which season is this?
10 seconds
/1
c.
What month is this?
10 seconds
/1
d.
What is today’s date?
10 seconds
/1
e.
What day of the week is this?
10 seconds
/1
2
a.
What country are we in?
10 seconds
/1
b.
What province are we in?
10 seconds
/1
c.
What city/town are we in?
10 seconds
/1
d.
IN HOME – What is the street address of this house?
10 seconds
/1
IN FACILITY – What is the name of this building?
e.
IN HOME – What room are we in? IN FACILITY – What floor are we on?
10 seconds
/1
3
SAY: I am going to name three objects. When I am finished, I want you to repeat
20 seconds
/3
them. Remember what they are because I am going to ask you to name them again in
a few minutes. Say the following words slowly at 1‐second intervals ‐ ball/ car/ man
Spell the word WORLD. Now spell it backwards.
30 seconds
/5
4
Now what were the three objects I asked you to remember?
10 seconds
/3
5
SHOW wristwatch. ASK: What is this called?
10 seconds
/1
6
SHOW pencil. ASK: What is this called?
10 seconds
/1
7
SAY: I would like you to repeat this phrase after me: No ifs, ands or buts.
10 seconds
/1
8
SAY: Read the words on the page and then do what it says. Then hand the person
10 seconds
/1
9
the sheet with CLOSE YOUR EYES on it. If the subject reads and does not close their
eyes, repeat up to three times. Score only if subject closes eyes
10
HAND the person a pencil and paper. SAY: Write any complete sentence on that
30 seconds
/1
piece of paper. (Note: The sentence must make sense. Ignore spelling errors)
PLACE design, eraser and pencil in front of the person. SAY: Copy this design please.
1 minute
/1
11
Allow multiple tries. Wait until person is finished and hands it back. Score only for
correctly copied diagram with a 4‐sided figure between two 5‐sided figures.
ASK the person if he is right or left‐handed. Take a piece of paper and hold it up in
30 seconds
12
front of the person. SAY: Take this paper in your right/left hand (whichever is non‐
dominant), fold the paper in half once with both hands and put the paper down on
the floor . Score 1 point for each instruction executed correctly.
Takes paper correctly in hand
/1
Folds it in half
/1
Puts it on the floor
/1
TOTAL TEST SCORE
/30
Note: This tool is provided for use in British Columbia with permission by Dr. William Molloy. This questionnaire should not be
further modified or reproduced without the written consent of Dr. D. William Molloy.
Provided by the Alzheimer’s Drug Therapy Initiative for physician use.
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