Form C1s - Mmse And Neuropsychological Battery (Spanish Module)

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phone: (206) 543-8637; fax: (206) 616-5927
e-mail: naccmail@u.washington.edu
website:
NACC Uniform Data Set (UDS) – Initial Visit Packet
Form C1S: MMSE and Neuropsychological Battery
(Spanish Module)
Center: ______________
ADC Subject ID:__ __ __ __ __ __ __ __ __ __
Form Date:__ __/__ __/__ __ __ __
NOTE: This form is to be completed by ADC or clinic staff. For test administration
ADC Visit #:__ __ __
and scoring, see UDS Coding Guidebook for Initial Visit Packet, Form C1.
Examiner’s initials:__ __ __
KEY:
If the subject cannot complete any of the following exams, please use
the following codes for test scores (except for the Trail Making Test):
95 = Physical problem
97 = Other problem
96 = Cognitive/behavior problem
98 = Verbal refusal
1.
Mini-Mental State Examination
1a. The administration of the MMSE was:
1 In ADC/
2 In home
3 In person–other
clinic
1) Language of MMSE administration:
1 English
2 Spanish
3 Other (specify):
_________________
1b. Orientation subscale score
1) Time:
__ __
(0–5) see Key
2) Place:
__ __
(0–5) see Key
1c. Intersecting pentagon subscale score:
__ __
(0–1) see Key
1d. Total MMSE score (using O-D-N-U-M)
__ __
(0–30) see Key
2 In home
3 In person–other
2. The remainder of the battery (below) was
1 In ADC/
clinic
administered:
2a. Language of test administration:
1 English
2 Spanish
3 Other (specify):
_________________
3.
Logical Memory IA – Immediate
3a. If this test has been administered to the subject
within the past 3 months, specify the date
previously administered:
__ __/__ __/__ __ __ __
(88/88/8888 = N/A)
(0–25; 88 = N/A)
1) Total score from the previous test administration:
__ __
3b. Total number of story units recalled from this current test
administration:
__ __
(0–25) see Key
4.
Digit Span Forward
4a. Total number of trials correct prior to two consecutive errors at the
__ __
(0–12) see Key
same digit length:
4b. Digit span forward length:
__ __
(0–8) see Key
(version 2.0, February 2008)
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