Standardized Mini Mental State Examination Form printable pdf download

St a nda rdize d M ini-M e nt a l St a t e Ex a m ina t ion (SM M SE)

DIRECTIO N S FO R ADM IN ISTRATIO N O F THE SM M SE

1. Before the questionnaire is administered, try to get the person to sit down facing you.

5. The following equipment is required to administer the instrument: A watch, a pencil,

Assess the peron’s ability to hear and understand very simple conversation, e.g. What

Page 2 of this SMMSE with CLOSE YOUR EYES written in large letters and two five-

is your name? If the person uses hearing or visual aids, provide these before starting.

sided figures intersecting to make a four-sided figure, and Page 3, a blank piece

2. Introduce yourself and try to get the person’s confidence. Before you begin, get the

of paper.

person’s permission to ask questions, e.g. Would it be all right to ask you same ques-

6. If the person answers What did you say?, do not explain or engage in conversation.

tions about your memory? This helps to avoid catastrophic reactions.

Merely repeat the same directions a maximum of three times.

3. Ask each question a maximum of three times. If the subject does not respond, score 0.

7. If the person interrupts (e.g. What is this for?), just reply: I will explain in a few min-

4. If the person answers incorrectly, score 0. Accept that answer and do not ask the

nutes, when we are finished. Now if we could proceed please... we are almost finished.

question again, hint, or provide any physical clues such as head shaking, etc.

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

1. (Allow 10 seconds for each reply)

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

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

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

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

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

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

2. (Allow 10 seconds for each reply)

What country are we in?

(accept exact answer only) ...........................................................................................

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

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

(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 buliding? (accept exact name of institution only).................................................

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

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

3. 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 slowly at approximatly 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) ..................................

Allow 20 seconds for reply; 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. Spell the word WORLD.

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

(allow 30 seconds; if the subject cannot spell world even with assistance, score 0) Refer to Page 2 for scoring instructions

5. Say:

N ow what were the three objects I asked you to remember? ......................................................................................

(score one point for each correct answer regardless of order; allow 10 seconds)

6. Show wristwatch.

Ask: W hat is this called? .................................................................................................................

(score one point for correct response; accept “ wristwatch” or “ watch” ; do not accept “ clock” or “ time” , etc.; allow 10 seconds)

7. Show pencil.

Ask: W hat is this called? ...........................................................................................................................

(score one point for correct response; accept “ pencil” only; score 0 for pen; allow 10 seconds for reply)

8. Say:

I would like you to repeat a phrase after me: N o ifs, ands, or buts.............................................................................

(allow 10 seconds for response. Score one point for a correct repetition. Must be exact, e.g. no ifs or buts, score 0)

9. Say:

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

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. This is covered in #3 directions

section above). Allow 10 seconds, score one point only if the subject closes eyes. The subject does not have to read aloud.

10. Hand

the person a pencil and paper (Page 3). Say: Write any complete sentence on that piece of paper. Allow 30

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

11. Place

design, pencil, eraser and paper in front of the person. Say: Copy this design please. Allow multiple tries. Wait

/ 1

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. Maximum time: One minute.

the

12. 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

following: 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.

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

Allow 30 seconds. Score one point for each instruction executed correctly.

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

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

This questionnire should not be modified or reproduced without the written consent of Dr. D. William Molloy.

TOTAL TEST SCORE:

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, Vol. 14, 1991a, pp.102-105.

ADJUSTED SCORE :

Page 1 SMMSE

Name :

Standardized Mini Mental State Examination Form

Related Articles

Related forms

Related Categories