2011 Standardized Mini-Mental State Examination (Smmse) Form (Page 3 of 4) in pdf

Name

Standardized Mini-Mental State

Examination (SMMSE)

DOB

CLINICIAN

SIGNATURE OF CLINICIAN

PATIENT EDUCATION / OCCUPATION

NAME OF PATIENT

PHN

DATE

I am going to ask you some questions and give you some problems to solve. Please try to answer as best you can.

1. Time: 10 seconds for each reply:

a) What year is this? (accept exact answer only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

b) What season is this? (accept either: last week of the old season or first week of a new season). . . . . . . . . . . . . .

/ 1

c) What month is this? (accept either: the first day of a new month or the last day of the previous month). . . . . . . .

/ 1

d) What is today’s date? (accept previous or next date). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

e) What day of the week is this? (accept exact answer only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

2. Time: 10 seconds for each reply:

a) What country are we in? (accept exact answer only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

b) What province are we in? (accept exact answer only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

c) What city / town are we in? (accept exact answer only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

d) (In home) What is the street address of this house? (accept street name and house number or equivalent in

rural areas).

(In facility) What is the name of this building? (accept exact name of institution only). . . . . . . . . . . . . . . . . . . . . .

/ 1

e) (In home) What room are we in? (accept exact answer only).

(In facility) What floor of the building are we on? (accept exact answer only). . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

3. Time: 20 seconds

Say: I am going to name three objects. When I am finished, I want you to repeat 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

approximately one-second intervals):

Ball

Car

Man

For repeated use: Bell, jar, fan; Bill, tar, can; Bull, bar, pan

Please repeat the three items for me. (score one point for each correct reply on the first attempt.) . . . . . . . . . . . . . . .

/ 3

If the person did not repeat all three, repeat until they are learned or up to a maximum of five times (but only score

first attempt).

4. Time: 30 seconds

Spell the word WORLD. (you may help the person to spell the word correctly) Say: Now spell it backwards please.

/ 5

If the subject cannot spell world even with assistance, score 0. Refer to Page 2 for scoring instructions.

5. Time: 10 seconds

Say: Now what were the three objects I asked you to remember? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 3

(score one point for each correct answer regardless of order)

6. Time: 10 seconds

Show wristwatch. Ask: What is this called? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

(score one point for correct response: accept “wristwatch” or “watch”; do not accept “clock” or “time”, etc.).

page 3 of 4

822221 Nov 29-11