Mini-Mental Status Screening Exam
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1
2MINI - MENTAL
STATUS
SCREENING
EXAM
PATIENT IDENTIFICATION
MAXIMUM
RESIDENT'S
DESCRIPTION
SCORE
SCORE
ORIENTATION:
5
TIME: What is the ( year ), ( month ), ( date ), ( day ), ( season ) ?
5
PLACE: Name ( city ), ( 2 neighboring states ), ( place ), ( floor ) ?
IMMEDIATE RECALL:
Name 3 objects ( table, penny, apple ). Ask the resident to repeat the 3
words. Give one point for each correct answer. Repeat the words until all
3
3 words are learned ... up to 3 trials. Tell the resident to remember the
words and that you will ask him / her to repeat the words in 5 minutes.
Count trials and record number:
Number of Trials: _______
ATTENTION:
5
Begin with 100 and count backwards by 7 ( "93, 86, 79, 72, 65"; stop after
5 answers ) -or- spell world backwards ("dlrow").
DELAYED RECALL: ( Wait a full 5 minutes )
3
Ask for the 3 objects registered above. Give 1 point for each correct
answer.
LANGUAGE:
2
NAMING: Ask the name of 2 objects ( pen, watch, etc. )
1
REPITITION: Repeat "no if's, and's or but's"
3
VERBAL COMMAND: "Take a paper in your right hand; fold it in half and
put it on the floor"
1
READING COMPREHENSION: "Close your eyes" ( over )
1
DRAWING: Copy a design ( over )
1
WRITING: Write a sentence ( over )
VISUAL IMPAIRMENT:
30
HEARING IMPAIRMENT:
MAXIMUM
TOTAL
EDUCATION LEVEL:
TOTAL SCORE
SCORE
S C O R E
A S S E S S M E N T
30 - 27 = Normal
9 - 0 =
Probable Advanced Dementia
NOTE: Not to be used as the ONLY
26 - 20 = Probable Mild Dementia
19 - 10 = Probable Moderate Dementia
tool to diagnose dementia.
RATER ( Print ):
RATER ( Signature ):
DATE:
Mini Mental Status Screening Exam_LONG TERM CARE
PAGE 1 of 2
8850372 Rev. 08/03
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