DATE:           TIME (24hr): 

"Please repeat these four words: "BALL",   "FLAG", "PENNY",  "TREE".

"So that you will remember these words, repeat them again."
(prompt missed words)

1.  What is today's date?  Correct:[];  within 5 days:[]; > 5 days off:[]

2.  Name as many animals as you can (stop after 30 seconds)

Ready, GO: []

0 []  1 []      2 []     3 []      4 []      5 []      6 []     7 []    8 []
            9 []    10 []  11 []    12 []    13 []    14 []  15 []  16 []
          17 []    18 []  19 []    20 []    21 []    22 []  23 []  + []   

3. Spell the word "WORLD" backwards:

                correct         wrong

        D     []             []
        L     []             []
        R     []             []
        O     []             []
        W     []             []

4.  What were the 3 words that I asked you to repeat? (click if recalled correctly)
                        correct   wrong
         "BALL"      []      []    
         "FLAG"      []      []               
         "PENNY"   []      []                
         "TREE"      []      [] 

  (date:  correct = 6, close = 3)

  (total = date + animals + # of letters correct + 3*recall)

                                         TOTAL SCORE: 

SCORING:       0  -  19   =  FURTHER DEMENTIA EVALUATION
                      20  -  23   =  ASK ADDITIONAL QUESTIONS
                      24  -         =  DEMENTIA UNLIKELY

SUGGESTED ADDITIONAL SCREENING QUESTIONS:

•     Draw a clock showing 8:20  (note numbering and hand placement)
•     Have you been depressed lately?  ________(consider depression)
•     Have you had difficulty with your memory ? ________________
•     Have you had problems sleeping recently? ________________

TEXT  for RECORDS (click here):