Mini Mental State Examination Checklist Template
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2MINI MENTAL STATE EXAMINATION CHECKLIST
1. Explains the procedure briefly to the patient.
The student then goes through each step of the examination. Give a mark here if the
sequence of (a), (b) and (c) is correct
a.
Checks patient’s orientation by asking:
‘What is the year, season, month, day, date?’
Records a mark out of 5 for this: 1 for each correct answer.
‘Where are we: country, province, city, hospital, room?’
Records a mark out of 5 for this: 1 for each correct answer
b. Checks patient’s memory – registration
Names three unrelated objects, taking 1 second to say each.
Then asks the patient to repeat all three. (Rehearses the answers if needed until the
patient has learnt all three).
Records one point for each correct answer.
c. Checks patient’s attention and calculation
2 methods acceptable here:
Asks patient to count backwards by 7s, starting with 100 (93, 86, 79, 72, 65). Stops
patient after these 5.
Scores the number of correct answers out of 5. OR
Asks the patient to spell the word ‘world’ backwards.
Scores the number of letters of letters in the correct place and order (out of 5 again).
d. Checks patient’s memory – recall
Asks the patient to repeat the names of the three objects learned in question b above.
Records 1 mark (out of 3) for each correct answer
e. Checks patient’s language – naming
Points to a pencil and a watch, asks the patient to name them as s/he points
Records 1 mark (out of 2) for each correct answer
f. Checks patient’s language – repetition
Asks patient to repeat after her/ him (one trial lonely allowed): ‘No ifs, ands or buts’.
Records 1 mark if correctly done.
g. Checks patient’s language – 3 stage command
Tells the patient, once only: ‘Take this paper in your right hand. Fold the paper in half.
Put the paper on the floor.’
Records 1 mark for each command correctly carried out.
g. Checks patient’s language – reading
Writes large on a piece of paper: ‘Close your eyes’; asks patient to read and carry out
instruction.
Records 1 mark if patient closes his/ her eyes
i. Checks patient’s language – writing
Asks patient to write a sentence of his/ her choice.
Records 1 mark if the sentence has a subject and a verb and make sense (spelling not
important)
j.
Checks patient’s ability to copy
Asks patient to copy a design provided (it is on the table).
Records 1 mark point if all 5 sides are preserved and if the intersecting sides form a diamond
shape
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