MMSE

Mini Mental State Examination

Please complete the form below.

First Name *

Last Name *

Date of birth *

Address *

What year is it?

CorrectINcorrect

accept exact answer only

What season is it?

CorrectINcorrect

(during the last week of the old season or the first week of a new season, accept either)

What month is this?

CorrectINcorrect

on the first day of a new month or the last day of the previous month, accept either

What is today’s date?

CorrectINcorrect

accept previous or next date

What day of the week is this?

CorrectINcorrect

accept exact answer only

What country are we in? *

CorrectINcorrect

accept exact answer only

What state are we in? *

CorrectINcorrect

accept exact answer only

What city/town are we in? *

CorrectINcorrect

accept exact answer only

What is the street address of this house? *

CorrectINcorrect

accept the street name and house number or equivalent in rural areas) RACF: What is the name of this building? (accept the exact name of the institution only)

What room are we in? *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

I am going to name three objects. When I am finished, 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. Ball *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

I am going to name three objects. When I am finished, 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. Car *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

I am going to name three objects. When I am finished, 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. Man *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

Spell the word WORLD (you may help the person to spell the word correctly). Say: Now spell it backwards please

DLROW

Now what were the three objects I asked you to remember? (Ball) *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

Now what were the three objects I asked you to remember? (Car) *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

Now what were the three objects I asked you to remember? (Man) *

CorrectINcorrect

accept exact answers only RACF: What floor of the building are we on? (accept exact answer only)

What is this called? *

CorrectINcorrect

What is this called? *

CorrectINcorrect

I would like you to repeat a phrase after me: No ifs, ands, or buts *

CorrectINcorrect

(allow ten seconds for response. Score one point for a correct repetition. Must be exact, e.g. no ifs or buts, score zero)

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Copyright © 1991 Charles S. Cleeland, PhD