1) What day of the week is it?
2) What is the year?
3) What province are we in?
4) Please remember these five objects. I will ask you what they are later.
Apple
Pen
Tie
House
Car
You may repeat the list for the patient up to a total of 3 times.
5) You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
a) How much did you spend?
b) How much do you have left?
6) I'm going to set a timer for one minute. Please name as many animals as you can.
1:00
7) What were the five objects I asked you to remember? (Select recalled words)
8) I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 4-2, you would say 2-4.
Practice (not scored): 8-7
6-4-8
8-5-3-7
9) This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock.
a) Hour markers
b) Time
10) Figure recognition
a) Please place an X in the triangle
b) Which figure is largest?
11) I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you some questions about it:
Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Toronto. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after.
a) What was the female's name?
b) What work did she do?
c) When did she go back to work?
d) What province she live in?
Results
Score: 0/30
Interpretation: —
Highschool education: 1-20=dementia, 21-26=mild neurocognitive disorder, 27-30=normal
Less than highschool: 1-19=dementia, 20-24=mild neurocognitive disorder, 25-30=normal