Brief Neurocognitive Assessment

Brief Neurocognitive Assessment

Instructions: click in the circles indicated for each item (e.g., right / wrong).

DATE      TIME (24hr) 

Ask the following questions:

right / wrong

Orientation to Person:
[]   [] 1. What is your last name?
[]   [] 2. What is your first name?
[]   [] 3. What is your birthday?
[]   [] 4. What is your birth year?
[]   [] 5. How old are you?    PERSON

Recollection of personal information:
[]   [] 6. In what county/city were you born?
[]   [] 7. In what state (country if not US) were you born?
[]   [] 8. What is your mother's maiden name?
[]   [] 9. How far did you go in school (years of education)?
[]   [] 10. What is your address (or phone number)?    PERSONAL HISTORY

Orientation to place:
[]   [] 11. What is the name of this clinic (place)?
[]   [] 12. What floor are we on?
[]   [] 13. What city are we in?
[]   [] 14. What county are we in?
[]   [] 15. What state are we in?    PLACE

Orientation to time:
[]   [] 16. What is today's date? (exact only)
[]   [] 17. What is the month?
[]   [] 18. What is the year?
[]   [] 19. What day of the week is today?
[]   [] 20. What season is it?    TIME/DATE

Recollection of historical information (PRESIDENTS)
[]   [] 21. Who is the President of the US?
[]   [] 22. Who was the President before him?
[]   [] 23. Who was the President before him?
[]   [] 24. Who was the first President of the US?
[]   [] 25. Name another US President?    PRESIDENTS:

Get the participant's attention, then say: "I am going to say five words that
I want you to remember now and later. The words are:

              SHIRT    SPOON    CHAIR    LAMP    HOUSE

Please say them for me now"

(Give the participant 3 tries to repeat the words. If unable after 3 tries, go to next
item.)

right / wrong
[]  /  [ ]   "SHIRT"
[]  /  [ ]   "SPOON"
[]  /  [ ]   "CHAIR"
[]  /  [ ]   "LAMP"
[]  /  [ ]   "HOUSE"    REPEATING 5 WORDS:

SAY: In one minute, tell me as many animals as you can think of, Ready, GO:
(click to start 60 second clock ->) []


You may click the numbers or use the right arrow to advance the count or the left arrow to reduce it.
  0 []
  1 []        2 []       3 []       4 []         5 []
  6 []        7 []       8 []       9 []       10 []
11 []      12 []     13 []     14 []       15 []
16 []      17 []     18 []     19 []       20 []
21 []      22 []     23 []     24 []       25 []
26 []      27 []     28 []     29 []       30 []
31 []      32 []     33 []     34 []       35 []
36 []      37 []     38 []     39 []     40+ []

CATEGORY FLUENCY 

SAY: "What were the five words I asked you to remember?"

  right / wrong
[]  /  [ ]   "SHIRT"
[]  /  [ ]   "SPOON"
[]  /  [ ]   "CHAIR"
[]  /  [ ]   "LAMP"
[]  /  [ ]   "HOUSE"    REPEATING 5 WORDS:

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  -----   Click this box to reset.

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

RESULTS:    

  0 -    5     normal, depending on age, education, complaints
  6 -  10     possible impairment
11 -  20     mild impairment
21 -  30     moderate impairment
31 -  40     severe impairment
41 -  50     profound/complete impairment

Note that this is a continuum of approximate descriptions, not a rigid classification.

Based on the Brief Alzheimer Screen (BAS)
Developed by Marta Mendiondo, Ph.D., Wes Ashford, M.D., Ph.D., Richard Kryscio, Ph.D., Frederick A. Schmitt, Ph.D.
J Alzheimers Dis. 2003 Dec 5:391-398.
ABSTRACT  -    PDF

See this link for powerpoint slides of Dementia and Alzheimer Screening, with BAS data.
See this link for earlier neuropsychiatric examination elements:
See this link for review of dementia and memory screening tests:
See this link for journal article addressing need for dementia screening.

Electronic form developed by J. Wesson Ashford, MD, PhD for www.Medafile.com
For comments, email to washford@medafile.com
See www.memtrax.com or MemTrax on AFA site for visual memory tests.
There is no individual or agency that takes responsibility for the results obtained with this test or this form.

MIND Diet Memory Loss