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Press to Start 2015 COGNISTAT ACTIVE FORMHold down left mouse key on any "?" for contextual help
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Name: _______________________________
First Name Family Name Gender: _______
Enter
Date of birth: ____________
Jan 1, 2013 Educ: ______
0 Yrs
mmm dd, yyyy
L R

City: _________________________ Age: ______

1 Yrs Lang: ______________
English Handedness: (click)

Current occupation:_________________ Nature of last job: ___________ Date last worked:___________

mmm dd, yyyy

Reason for hospitalization or visit to clinic: __________________________ Date of injury: ___________

if any

Date of testing: __________ Time: ______ Inpatient: Outpatient: ✔ Location: ___________________

Past Medical History 1._________________________________________________

2._________________________________________________
3._________________________________________________
4._________________________________________________

Past Psychiatric History 1._________________________________________________

2._________________________________________________
3._________________________________________________
4._________________________________________________

Factors Potentially Influencing Test Performance

(Check Y or N for each item) ? Comments ?
CNS-Active Medications, Dosage
Y N and Frequency, Check if None
? Neurological Condition ____________________ ________________________
? Visual Impairment ____________________ ________________________
? Hearing Loss / Tinnitus ____________________ ________________________
?
Dizziness / Vertigo ____________________ ________________________
?
Pain ____________________ ________________________
?
Substance Abuse ____________________ ________________________
?
Sleep Deprivation / Insomnia ____________________ ________________________
?
Poor Cooperation ____________________ ________________________
?
Psychiatric Disorder ____________________ ________________________
?
Fatigue ____________________ ________________________
? English as a 2nd Language ____________________ ________________________
? Learning Disorder ____________________ ________________________
? ADHD ____________________ ________________________
? Litigation ____________________ ________________________

Cognistat Inc. © 2015 First Name Page 1 of 8

This form no longer valid after Jan 31, 2016

 I. LEVEL OF CONSCIOUSNESS:

?
Alert Lethargic Fluctuating

_________________________________________________________________________________

II. ORIENTATION
A. Person Other Response
Correct Incorrect

1. What is your full name? 0

2. What is your present age? 0

B. Place
? 1. Where are you right now? 0

? 2. What city are we in? 0

C. Time
? 1. What is the year? 0

2. What month is it? 0

? 3. What day of the week is it? 0

4. What is the date? 0

? 5. What time is it? 0

Total Score _________

0

III. ATTENTION
?
A. Digit Repetition
Other Response
?
Screen: 8-3-5-2-9-1 Pass Fail ________________________

? Metric: Discontinue after two misses at any level.

Y N Y N Y N Y N
3-7-2 0 5-1-4-9 0 8-2-5-3-9 0 2-8-5-1-6-4 0

4-9-5 0 9-2-7-4 0 6-1-7-3-8 0 9-1-7-5-8-2 0

Other Responses 0
Total Score _________
_

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 Show Hide

Option ✔ Click to display optional 7, 8 and 9 digit sequences, which can be used for additional qualitative information only.

?
B. Four Word Registration (Part 1) Give the four words (from group A, B or C) until the patient is able to repeat all
four words on two sucessive trials. Click if correct and record incorrect answers.
The Clock starts automatically when registration is complete.
Clock

Select Word Group A, ✔ B or C

Incorrect Answers
1st 2nd 3rd 4th 5th 6th 7th 8th
Robin ___________________________
Carrot ___________________________
Piano ___________________________
Green ___________________________

IV. LANGUAGE
?
A. Speech Sample: Fishing Picture Record patient’s response verbatim.

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Examiner's Comments: ________________________________________________________________________

?
B. Comprehension Place a pen, some keys, a coin, an index card and three other
objects (e.g. paper clip, rubber band, etc.) in front of the patient.

? Screen: 3-step command: “Turn over the paper, hand me the pen, and point to your nose.”
Pass Fail

?
Metric Other Response
Correct Incorrect

a. Pick up the pen. 0 __________________________________

b. Point to the floor. 0 __________________________________

c. Hand me the keys. 0 __________________________________

d. Point to the pen and pick up the keys. 0 __________________________________

e. Hand me the paper and point to the coin. 0 __________________________________

f. Point to the keys, hand me the pen, and 0 __________________________________

pick up the coin.
Total Score 0
_______
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 C. Repetition

?
Screen: The beginning movement revealed the composer’s intention. Pass Fail

____________________________________________________________________________________

? Metric: Patient may make two attempts to repeat the statement.

1st Attempt
Correct
2nd Attempt
Correct
Incorrect Other Response

a. Out the window. 0 ___________________________

b. He swam across the lake. 0 ___________________________

c. The winding road led to the village. 0 ___________________________

d. He left the latch open. 0 ___________________________

e. The honeycomb drew a swarm of bees. 0 ___________________________

f. No ifs, ands or buts 0 ___________________________

Total Score 0
__________
D. Naming

? Screen
Y N Y N Y N Y N
a) Pen b) Cap or Top c) Clip d) Point, Tip, or Nib

Pass Fail
?
Metric: (If incorrect, record response)

Other Response Other Response

Y N Y N

a. Shoe 0 __________________ e. Horseshoe 0 __________________

b. Bus 0 __________________ f. Anchor _ 0 __________________

c. Ladder 0 __________________ g. Octopus 0 __________________

d. Kite 0 __________________ h. Xylophone 0 __________________

Total Score _________

0

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V. CONSTRUCTIONS

? Screen: Visual Memory

Present stimulus sheet for 10 seconds, then have patient draw the two figures from memory. Must be
perfect to pass. The examiner may wish to have patients who fail the screen to copy the two figures.

Pass Fail

? Metric: Tile Designs

Present the tiles and click the boxes to start and stop the timers.
Click Y or N for correct. Scores are automatically calculated.

Start Stop Time (secs) Y N

Place tiles in front of patient as
shown here: 0
1. Design

0
2. Design

0
3. Design

0
Total Score _________

?
VI. MEMORY Four Word Memory Test (Part 2)
Click Box for Elapsed Time Time (Mins) Answers can be recalled without prompting,
or recalled with category prompt,

or recognized only from a list.

Words Category Recognition

Word Category Recognition Incorrect
Correct Correct Correct
Robin Bird Sparrow, robin, bluejay 0

Carrot Vegetable Carrot, potato, onion 0

Piano Musical Instrument Violin, guitar, piano 0

Green Color Red, green, yellow 0

Other Responses

Total Score 0
__________

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VII. CALCULATIONS
? Screen: Pose the math question and start the timer. Stop the timer when answered. Enter the
response. Click on Y or N. Scoring is automatic. Must be correct in 20 secs or less .

Response
Start Stop Time (secs)
How much is 5 x 13? ________

Pass Fail

Metric: Problems may be repeated but time runs continously from first presentation.
?

Response
Y N
Start Stop Time (secs)
How much is 5 + 3? ___________ 0

How much is 15 + 7? ___________ 0

How much is 31 - 8? ___________ 0

How much is 39 ÷ 3? ___________ 0

Total Score _________

0

VIII. REASONING

A. Similarities: Explain: “A hat and coat are alike because they are both articles of clothing.”
If patient does not respond, encourage; if patient gives differences, score 0.

? Screen: Painting & Music (Must be abstract—only “art,” ‘artist,” or “forms of art” are acceptable.)

Pass Fail

____________________________________________________________________________________

? Metric: Answers are correct if fully abstract; imprecise if

concrete; or incorrect. See Manual for examples.

Abstract Idea Other Responses

Correct Imprecise Incorrect

a. Rose-Tulip Flowers 0
________________________________

b. Bicycle-Train Transportation 0 ________________________________

c. Watch-Ruler Measurement 0 ________________________________

d. Corkscrew-Hammer Tools 0 ________________________________

0
Total Score _________

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First Name
 B. Judgment

? Screen: What would do if you were stranded in an airport 1,000 miles from home, with only $1.00 in your pocket?

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Pass Fail

? Metric: Score as correct, partially correct or incorrect.

a. What would you do if you woke up one minute before 8:00 a.m. and remembered
that you had an important appointment downtown at 8:00 o’clock? Correct Partial Incorrect

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

b. What would you do if you were walking beside a lake and saw that a
two year old child was playing alone at the end of a pier? Correct Partial Incorrect

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

c. What would you do if you came home and found that a broken
pipe was flooding the kitchen? Correct Partial Incorrect

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

0
Total Score _________

?
IX. Patient’s Comments                                   Record patient's response verbatim

Was there anything that distracted you today or made it hard to concentrate?

___________________________________________________________________________________________________________________

How do you feel you did on the questions today?

___________________________________________________________________________________________________________________

?
X. Examiner's Observations
(re: attitude, fatigue, cooperation, awareness, irritability, etc.)
(see p 29 of the 2013 Cognistat Manual)

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Generate Summary
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 XI. Cognistat Summary
Orientation:

Attention:

Language:

Constructions:

Memory:

Summary:

?
MCI Index: The MCI Index is designed to provide guidance regarding diagnostic questions of mild cognitive impairment or dementia. It is
(0 to 6) not intended for use in cases with isolated and more specific cognitive deficits such as amnestic or aphasic disorders.
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Cognitive Status Profile†

Name: First Name Age: Date of Exam:
Occupation: Yrs. of Educ: Date Last Worked:

Average Range

Mild Impairment

Moderate Impairment

Severe Impairment

0 0 0 0 0 0 0 0 0 0

† THE VALIDITY OF THIS EXAMINATION DEPENDS ON ADMINISTRATION IN STRICT ACCORDANCE WITH THE 2013 COGNISTAT MANUAL.
Note: Normal scores cannot be taken as evidence that brain pathology does not exist. Similarly, scores falling in the mild, moderate
or severe range of impairment do not necessarily reflect brain dysfunction (see section of the Cognistat Manual entitled “Cautions in Interpretation”).
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duplicated or otherwise reproduced without the prior written consent of the copyright owner.
Cognistat Inc., Headquarters: 4480 Côte de Liesse, Suite #355, Montreal, QC, H4N 2R1 Canada
Phone: +1-(514)-337-7337 ● Fax: +1-(514)-336-6537 ● Web: www.cognistat.com
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Cognistat Inc. © 2015 Rev 30.99 Page 8 of 8