MONTREAL COGNITIVE ASSESSMENT (MOCA) Date of birth DATE: ETE Draw CLOCK (Ten past eleven) points (points) ea tI [] Contour Numbers Hands Cerra Read lst of words, subject, Face | vewver | cHurcH | palsy | RED ‘must repeat them. Do3 trials, Do arecall afters minutes, teak hd tial Ba Read Istof digits (digit sec). Subjecthas toepeat them in the forwardorder_ [ ] 2185 4 Subject has to repeat them in the backwardorder [ ] 7 4 2 Read list of letters. The subject must tap with Hishand at each letter A, Nopornisf 2aerom L_] FRACMNAAJKLBAFAKDEAAAJAMOFAAB Seval7 subtraction starting at 00 U1ss [186 [17 lin Tl6s orsconc subtrtins:3 pts 20s coet2 pts yore pho cone pt Repeat lonly know that ohn the one tohelp today. | ] ‘The cat alwayshhid under the couch when dogs were in the room, [_] oes Flueny/ Name maximum numberof words none minut that begin wth heleter [|] Iwo uwork) CEALAGUAMM Sitar betweeneg.banana-orange=frut [ ]train—bicycle [ ]watch-ruler DELAVED RECALL Ma wranocue | [ ] ul ul U1 | LT | scion, ategory cue oa ‘Mallple dhoce cue TMM [ Joate [Month [ ]vear [ ]bay [ Imace Jory Normat 26/30 | TOTAL /30 ‘Add 1 polntits yr edu ©ZNasredline HD Version7.0 wwwrmocatest.org ‘Aekinstered b Reprinted with permission of Dr Z. Nasreddine.