COGNITIVE QUESTIONNAIRE

       DATE           TIME (24hr) 

ORIENTATION TO PERSON, PLACE, AND TIME:
              Tell me your full name.
right / wrong
   1. Spontaneously gives first name. - must click to start test
   2. Spontaneously gives last name.
   3. How old are you?
   4. What is your date of birth? (score right only if patient knows day, month, year)
   5. Where were you born? (accept any reasonable answer)
   6. How far did you go in school? Education: (please record # of years if reliable) 
                  unknown []   0 []
                              1 []       2 []       3 []       4 [] (4th grade)
                              5 []       6 []       7 []       8 [] (8th grade)
                              9 []     10 []     11 []     12 [] (finished high school)
                            13 []     14 []     15 []     16 [] (finished college)
                            17 []     18 []     19 []     20+ []
   7. Where do you live now? (accept address or city/town)
                            PERSON 
right / wrong
   8. What is the name or address of this place?
   9. What floor of this building are we on?
   10. What city/town are we in?
   11. What county are we in?
   12. What state are we in?
                            PLACE 

REMOTE MEMORY - PRESIDENTS:
right / wrong
   18. Who is the President of the United States?
   19. Who was the President before him?
                            REMOTE MEMORY 

REPETITION:
I am going to say four words. After I have said them, 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.

They are: "Beauty", "Table", "Honor", and an "Apple".

Could you please repeat these for me?
The items should be read at a rate of 1 per second, speaking clearly and audibly.
You are allowed to read the words only once before scoring.
Score on first trial
right / wrong
   20. "Beauty"
   21. "Table"
   22. "Honor"
   23. "Apple"
                            IMMEDIATE RECALL 
Repeat the words until: 1) the subject correctly repeats all three or
2) 3 total trials have been presented (including initial presentation).
After the subject has said them once correctly, ask:
    "Please repeat them once more so you will remember them."
   24. Repeats correctly on second request

NAMING:

25.  Name as many animals as you can, GO: (stop after 30 seconds)

Ready, GO: (click to start ->) [] CLOCK

Hold up a wrist watch and ask: what is this called? Repeat with a pen.
right / wrong
   45. WRIST WATCH
   46. PEN
                            OBJECT NAMING 

RECALL:
Now, what were the four words I asked you to remember?
(This should administered as soon as the naming item is completed.
Cueing is allowed if the subject is not able to recall words,
but credit is not given for any word recalled after a cue.)
right / wrong
   47. "Beauty"
   48. "Table"
   49. "Honor"
   50. "Apple" must click to end test
                            DELAYED VERBAL RECALL 

TOTAL     (COGNITIVE QUESTIONNAIRE maximum score = 50)

41 - 50   normal, depending on age, education, complaints
31 - 40   mild impairment
21 - 30   moderate impairment
11 - 20   severe impairment
  0 - 10   profound impairment

TEXT FOR YOUR RECORDS:
- To copy text, highlight all text (hit "Ctrl-A") or text to be copied, then hit "Ctrl-C".
- To paste into your patient's record, position the cursor then hit "Ctrl-V"

Start TIME (24hr):      End TIME (24hr):      Total Time (seconds):