Name:

MINI-MENTAL Birth date: Age:

STATE Contact Number:
EXAMINATION Address:

(MMSE)
One point for each DATE: Sept. Sept. Sept.
answer

ORIENTATION ……/ 5 ……/ 5 ....../ 5

Year Season Month Date Day

Country Region Municipality Town Street ……/ 5 ……/ 5 ....../ 5

REGISTRATION
Examiner names three objects (e.g. apple, banana, orange) ……/ 3 ……/ 3 ....../ 3
and asks the patient to repeat (1 point for each correct. THEN
the patient learns the 3 names repeating until correct).

ATTENTION AND CALCULATION

Subtract 7 from 100, then repeat from result. Continue five ……/ 5 ……/ 5 ....../ 5
times: 100, 93, 86, 79, 65. ().

RECALL ……/ 3 ……/ 3 ....../ 3

Ask for the names of the three objects learned earlier.

LANGUAGE ……/ 2 ……/ 2 ....../ 2

Name two objects (e.g. ballpen, watch).

Repeat “Hindi, at, ngunit”. ……/ 1 ……/ 1 ....../ 1

Give a three-stage command. Score 1 for each stage. (e.g.

……/ 3 ……/ 3 ....../ 3
“Place index finger of right hand on your nose and then on
your left ear”).
Ask the patient to read and obey a written command on a
……/ 1 ……/ 1 ....../ 1
piece of paper. The written instruction is: “Close your eyes”.

Ask the patient to spell LAKAS” backwards: SAKAL

……/ 1 ……/ 1 ....../ 1

COPYING: Ask the patient to copy a pair of intersecting pentagons

……/ 1 ……/ 1 ....../ 1

TOTAL: ……/ ……/ ....../

MMSE scoring 30 30 30
24-30: no cognitive impairment
18-23: mild cognitive impairment
0-17: severe cognitive impairment
 Geriatric Depression Scale (GDS)

Direction: Choose the best answer for how you have felt over the past week
ITEMS September Comments
Yes No
1. Are you not satisfied with your life?

2. Have you dropped many of your activities and

interests?

3. Do you feel that your life is empty?

4. Do you often get bored?

5. Are you in poor most of the time?

6. Are you afraid that something bad is going to happen

to you?

7. Do you feel lonely most of the time?

8. Do you often feel helpless?

9. Do you prefer to stay at home, rather than going out

and doing new things?

10. Do you feel you have more problems with memory

than most?

11. Do you think it is not wonderful to be alive now?

12. Do you feel worthless the way you are now?

13. Do you feel lack of energy?

14. Do you feel that your situation is hopeless?

15. Do you think that most people are better off than

you are?

TOTAL SCORE

*Score 1 point for each YES answer. A score of more than or equal to 5 points suggest depression and requires further assessment

Declaration: I hereby acknowledge that the given information is correct and is in accordance to the best of my knowledge.

___________________________ _____________ _____________________________________
Name and Signature of Patient Date Name and Signature of Nursing Student
 Katz Functional Index
Independence in Activities of Daily Living
Activities of Daily Independence Dependence Points
Living (ADL) (1 Point) (0 Points) (1 or 0)

Description NO supervision, direction or WITH supervision,

personal assistance. direction, personal
assistance or total care.
BATHING
(1 POINT) Bathes self (0 POINTS) Need help with
completely or needs help in bathing more than one part
bathing only a single part of the of the body, getting in or
body such as the back, genital out of the tub or shower.
area or disabled extremity. Requires total bathing
DRESSING
(1 POINT) Get clothes from (0 POINTS) Needs help with
closets and drawers and puts dressing self or needs to be
on clothes and outer garments completely dressed.
complete with fasteners. May
have help tying shoes.
TOILETING
(1 POINT) Goes to toilet, gets on (0 POINTS) Needs help
and off, arranges clothes, cleans transferring to the toilet,
genital area without help. cleaning self or uses
bedpan or commode.
TRANSFERRING
(1 POINT) Moves in and out of (0 POINTS) Needs help in
bed or chair unassisted. moving from bed to chair or
Mechanical transfer aids are requires a complete
acceptable transfer.
CONTINENCE
(1 POINT) Exercises complete (0 POINTS) Is partially or
self control over urination totally incontinent of bowel
and defecation. or bladder
FEEDING
(1 POINT) Gets food from plate (0 POINTS) Needs partial or
into mouth without help. total help with feeding or
Preparation of food may be requires parenteral
done by another person. feeding.
*Score 1 point for each INDEPENDENCE answer. Compute the total score. Client score should be between 0 (lowest) and 6
(highest). A score of 6 indicates complete independence, 4 implies moderate impairment, and2 or less suggests
severe functional impairment

Declaration: I hereby acknowledge that the given information is correct and is in accordance to the best of my knowledge.


___________________________ _____________ _____________________________________
Name and Signature of Patient Date Name and Signature of Nursing Student
 CLOCK DRAW TEST (CDT)

Instruction/Administration
The test is administered as follows:
1. Instruct the patient to listen carefully, remember and mention 3 unrelated words (apple, yellow, and cloud)
2. Ask the patient to repeat the 3 words (apple, yellow, and cloud).
3. Instruct the patient to draw the face of a clock on a blank sheet of paper
4. After ask the patient to put the numbers on the clock face (1-12)
5. Ask him or her to draw the hands of the clock to read a specific time, such as 05:45.
6. These instructions can be repeated and give the patient as much time as needed to complete the task.
Remember: the CDT serves as the recall distractor.
3. Ask the patient to repeat the 3 previously presented word (apple, yellow, and cloud).

Scoring
Give 1 point for each recalled word after the CDT distractor. Score 1–3.
O (regardless of CDT results)- positive screen for dementia.
1 or 2 with an abnormal CDT- positive screen for dementia.
1 or 2 with a normal CDT- negative screen/ absence of dementia.
3- negative screen/absence of dementia.

CDT Scoring
Normal CDT- all numbers are present, numbers in their correct sequence, correct position of second hand.
Abnormal CDT- some numbers are missing, not in the correct sequence, incorrect position of second hand.
Nursing Documentations

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Printed Name and Signature

Student No.: _____________

Reflections

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