1. What year is this?
2. What season is this?
3. What month of the year is this?
4. What is today’s date?
5. What day of the week is this?
6. What country are we in?
7. What county are we in?
8. What city/town are we in?
9. In the home: What is the street address of this house? In the clinic: What is the name of this hospital/building?
10. In the home: What room are we in? In the clinic: What floor of the building are we on?
11. Registration
I am going to name three objects.
After I have said all 3 objects, I would like you to repeat them.
Try to remember what they are because I am going to ask you to name them again in a few minutes.
So the 3 objects are: ball – car – man
Say them slowly at approximately 1 second intervals
Please repeat the 3 items for me.
Allow 20 seconds for response
First attempt
ball car man
12. Attention and calculation Could you spell the word WORLD
You may help the participant to spell the word correctly
Now spell it backwards please
Allow 30 seconds to spell it backwards DLROW
13 Recall
Now what were the 3 objects that I asked you to remember?
Allow 10 seconds for response.
14. Show wristwatch and ask What is this called?
allow 10 seconds
15. Show pencil and ask What is this called?
16. Repetition of phrase
I would like you to repeat this phrase after me:
“No ifs, ands or buts”.
Allow 10 seconds for response Note participant’s answer
17. ‘Close your eyes’
Read the words on this page and then do what it says
Hand the participant the laminated sheet ‘close your eyes’
Allow 10 seconds
If the participant just reads and does not then close eyes, you may repeat ‘Read the words on this page and then do what it says’ to a maximum of three times. Participant does not have to read out loud. 23
Score
18. Following instructions
Could I just check, are you right or left handed? (Circle which ) Take a piece of paper
hold it up in front of the participant and say
Take this paper in your ………..hand,
(insert left if right handed or right if left handed)
fold the paper in half once with both hands and put the paper down on your lap.
Only give the participant the paper after completing all the instructions Allow 30 seconds
Takes paper in correct hand Folds it in half
Puts it on lap
19. Sentence
Hand participant a pencil and paper
Please could you write any complete sentence on that piece of paper.
allow 30 seconds
Interviewer to copy sentence here:
20. Copy diagram
Place design, pencil, eraser and paper in front of the participant
Please could you copy this design for me.
Allow multiple tries until the participant has finished and hands it back.
Maximum time 1 minute.
26. Were any items ‘not asked’?
27. Reasons why items not asked
Code all that apply
28. Were any items ‘refused’?
29. Reasons why items refused
Code all that apply
30 Was the participant’s performance on attempted questions limited by any problems unrelated to cognitive function?
31. If Yes, what problem(s)
Code all that apply

1-10:
Correct
Incorrect
Not Asked

11:
If the participant could not repeat all 3 words in the first attempt, then reiterate ball – car – man, until the participant can repeat all three, up to 5 attempts.
Note the number of attempts

12-16:
Correct
Incorrect
Not Asked

17:
Did the participant close their eyes?
Yes
No
Item omitted.

18.
Takes paper in correct hand
Folds it in half
Puts it on lap

19-20:
Correct
Incorrect
Not Asked

26:
Yes
No
Not applicable Item not completed

27:
Visual impairment
Hearing impairment
Speech impairment
Language barrier
Unable to comprehend task
Literacy problem (unable to read/write) Reduced manual dexterity
Distress
Fatigue Interviewer error
Other reason (specify)
Not applicable Reason not entered

28.
Yes
No
Not applicable Item not completed

29.
Participant refused – no reason
Participant refused – other reason (specify)
Relative/carer refused – no reason
Relative/carer refused – other reason (specify)
Not applicable Reason not entered
The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location.
The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location.
The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location.

30.
Yes
No
Not applicable Item not completed

31.
Visual impairment Hearing impairment Speech impairment Language barrier
Literacy problem (unable to read/write) Reduced manual dexterity
Distress
Fatigue
Other reason (specify)
Not applicable Reason not entered

General health
Hearing
Eyesight
Blood pressure – sitting
Smoking
Hand grip strength