Form C1s - Mmse And Neuropsychological Battery (Spanish Module) (Page 2 of 2) in pdf

Form C1s - Mmse And Neuropsychological Battery (Spanish Module) Page 2

Center: ______________

ADC Subject ID:__ __ __ __ __ __ __ __ __ __

Form Date:__ __/__ __/__ __ __ __

ADC Visit #:__ __ __

NOTE: This form is to be completed by ADC or clinic staff. For test administration

and scoring, see UDS Coding Guidebook for Initial Visit Packet, Form C1.

Digit Span Backward

5a. Total number of trials correct prior to two consecutive errors at the

__ __

(0–12) see Key

same digit length:

5b. Digit span backward length:

__ __

(0–7) see Key

Category Fluency

6a. Animals – Total number of animals named in 60 seconds:

__ __

(0–77) see Key

6b. Vegetables – Total number of vegetables named in 60 seconds:

__ __

(0–77) see Key

KEY 2: If necessary, use the following codes for the Trail Making Test only:

995 = Physical problem

997 = Other problem

996 = Cognitive/behavior problem

998 = Verbal refusal

Trail Making Test

7a. Part A–Total number of seconds to complete

__ __ __

(0–150) see Key 2

(if not finished by 150 seconds, enter 150):

1) Number of commission errors

__ __

(0–40)

2) Number of correct lines

__ __

(0–24)

7b. Part B–Total number of seconds to complete

__ __ __

(0–300) see Key 2

(if not finished by 300 seconds, enter 300):

1) Number of commission errors

__ __

(0–40)

2) Number of correct lines

__ __

(0–24)

. WAIS-R Digit Symbol

8a. Total number of items correctly completed in 90 seconds:

__ __

(0–93) see Key

Logical Memory IIA – Delayed

9a. Total number of story units recalled:

__ __

(0–25) see Key

(0–85 minutes)

9b. Time elapsed since Logical Memory IA – Immediate:

__ __

(88 = N/A)

(99 = Unknown)

10.

Boston Naming Test (30 items – Spanish)

10a. Total score:

__ __

(0–30) see Key

Check only one box below:

11.

Overall Appraisal

11a. Based on the UDS

1 Better than normal for age

4 Three or more scores

neuropsychological

are abnormal or lower

2 Normal for age

examination, the subject’s

than expected

3 One or two test scores

cognitive status is deemed:

0 Clinician unable to

abnormal

render opinion

UDS Initial Form C1S (Spanish module): MMSE and Neuropsych Battery (version 2.0, February 2008) Page 2 of 2

Form C1s - Mmse And Neuropsychological Battery (Spanish Module) Page 2

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