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

Name

Standardized Mini-Mental State

Examination (SMMSE)

DOB

7. Time: 10 seconds

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

/ 1

(score one point for correct response; accept “pencil” only; score 0 for pen)

8. Time: 10 seconds

Say: I would like you to repeat a phrase after me: No ifs, ands or buts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

Score one point for a correct repetition. Must be exact, e.g. no ifs or buts, score 0).

9. Time: 10 seconds

Say: Read the words on this page and then do what it says. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

Then, hand the person the sheet with CLOSE YOUR EYES on it. If the subject just reads and does not close eyes,

you may repeat: Read the words on this page and then do what it says (a maximum of three times). Score one point

only if the subject closes eyes. The subject does not have to read aloud.

10. Time: 30 seconds

Hand the person a pencil and paper. Say: Write any complete sentence on that piece of paper. . . . . . . . . . . . . . . . . .

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Score one point. The sentence must make sense. Ignore spelling errors.

11. Time: 1 minute maximum

Place design, eraser and pencil in front of the person. Say: Copy this design please. . . . . . . . . . . . . . . . . . . . . . . . . .

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Allow multiple tries. Wait until the person is finished and hands it back. Score one point for a correctly copied

diagram. The person must have drawn a four-sided figure between two five-sided figures.

12. Time: 30 seconds

Ask the person if he is right or left handed. Take a piece of paper, hold it up in front of the person and 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 one point for each instruction executed correctly.

Takes paper in correct hand . . . . . . . . . . . . . . . . . . . .

/ 1

Folds it in half . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

Puts it on the floor . . . . . . . . . . . . . . . . . . . . . . . . . . .

/ 1

TOTAL TEST SCORE:

. . . . . . . . . . . . . . . . . . . . . .

/ 30

ADJUSTED SCORE: . . . . . . . . . . . . . . . . . . . . . . . . .

Comments:

Please note: This tool is provided for use in British Columbia with permission by Dr. D. Willam Molloy. This questionnaire should not be further modified or reproduced without the written

consent of Dr. D. William Molloy. Molloy DW, Alemayehu E, Roberts R. Reliability of a standardized Mini-Mental State Examination compared with the traditional Mini-Mental State

Examination. American Journal of Psychiatry,1991;148(1): 102-105.

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