NAME MONTREAL COGNITIVE ASSESSMENT (MOCA®) Education Date of birth: Version 7.2 Alternative Version Sex: DATE: Rez uence Draw CLOCK (Five past four) mon Copy rectangle | (3p0ins) el C1 ee Contour Numbers Hands / PET BCs b WEENIE ccc ist of words subject must Truck | BANANA | VIOLIN | DESK | GREEN repeat them.Do 2 trials evenif It talis success aeuall Do a recall ater 5 minutes. eee 2nd trial EAMES Read list of digits (1 digit/ sec). Subject has to repeat them in the forward order Subject has to repeat them in the backward order Read lst of letters. The subject must tap with his hand at each letter A. No polntsif 2 2erors [_] FBACMNAAJKLBAFAKDEAAAJAMOFAAB Serial 7 subtraction starting at 90 [183 (176 [ ] 69 [162 [155 4or5 conact subtractions 3 pts 2or3conect: 2 pts, 1comact 4 pe Ocorect O pt /3 TETSU ®epeat: Abird can fy into closed windows when it's dark and windy. [ ] The cating grandmother sent groceries over a week ago. [ J Fluency / Name maximum number of words in one minute that begin with the letter S [_] ___ 211 words) TALES similarity between eg, carrot - potato = vegetable. [ ] diamond-ruby [_ ] cannon rifle Has to recall words | TRUCK BANANA VIOLIN DESK | GREEN | Points for wrHwocue | [J ia 1] C1 | 01 | iatey Gategoryave Pawan Optional ‘Multiple choice cue ORIENTATION [ ] Date [ ] Month [1 Year [ ] Day [| Place [ ]city SP GIL ‘Adapted by :Z. Nasreddine MD, N. Phillips PhD, H. Chertkow MD Normal 226/30 © Z.Nasreddine MD www.mocatest.org Administered by TOTAL —/30 Add 1 pointit_$12yredu