Column Name in Spreadsheet Value Type

Catalog ID NULL String

Age NULL Integer
Gender M|F String
Race Caucasian | Black | Other String
Orientation GIVE ONE POINT FOR EACH CORRECT ANSWER,
ENTER "1" IF CORRECT, "0" IS INCORRECT NULL String
What year is it? 0|1 Integer
What season of the year is it? 0|1 Integer
What is today's date? 0|1 Integer
What day of the week is today? 0|1 Integer
What month are we in? 0|1 Integer
What state/province are we in? 0|1 Integer
What country are we in? 0|1 Integer
What town are we in? 0|1 Integer
Can you tell me the name of this place? 0|1 Integer
What floor of the building are we on? 0|1 Integer

Score 0|1|2|3 Integer

Trials 1|2|3|4|5|6 Integer

Score 0|1|2|3|4|5 Integer

Score 0|1|2|3 Integer

Score 0|1|2 Integer

Score 0|1 Integer

Score 0|1|2|3 Integer

Score 0|1 Integer

Score 0|1 Integer

Score 0|1 Integer
Total Score (0 - 30) NULL Integer
Level of consciousness Alert | Drowsy | Stupor | Coma String
Does this patient have the capacity to recall or record symptoms that
could be judged as an ischemic attack? Yes | No String
Number of Days from Stroke NULL Integer
Code number of person conducting the interview: NULL String
Notes

B. REGISTRATION Ask the patient if you may test her/his

memory. Then say the names of three unrelated objects (apple,
table, penny) clearly and slowly, about one second for each. After
you have said all three, ask her/him to repeat them. This first
repetition determines her/his score (0-3) but keep saying them
until she/he can repeat all three, up to six trials. If she/he does not
eventually learn all three, recall cannot be meaningful tested.

C. ATTENTION AND CALCULATION Ask the patient to begin

with 100 and count backwards by 7. Stop after five subtractions
(93, 86, 79, 72, 65). Score the total number of correct answers. If
the patient refuses to perform this task, then ask her/him to spell
the word "world" backwards. This score is the number of letters in
correct order (e.g. dlrow = 5, dlorw = 3). It is noted that "world" is
not used as an alternative upon failure of the patient to perform
serial 7’s.
D. RECALL Ask the patient if she/he can recall the three words
you previously asked her/him to remember.
E. NAMING A. Show the patient a wrist watch and ask her/him
what it is. B. Repeat for a pencil.
F. REPETITION Ask the patient to repeat this phrase after you -
"No Ifs, Ands or Buts." Allow only one trial.

G. 3-STAGE COMMAND Have the patient follow this 3-stage

command - "Take a paper in your right hand, fold it in half, and
put it on the floor". Score one point for each part correctly
executed.

H. REACTING On a blank piece of paper print this sentence

"Close your eyes" in letters large enough for the patient to see
clearly. Ask her/him to read it and do what it says. Score one
point if she/he actually closes her/his eyes.

Give the patient a blank piece of paper and ask her/him to write a
sentence for you. Do not dictate a sentence. It is to be written
spontaneously. It must contain a subject and verb and be
sensible. Correct grammar and punctuation are not necessary.
On a clean piece of paper, draw intersecting pentagons, each
side about one inch, and ask her/him to copy it exactly as it is. All
ten angles must be present and two must intersect to score one
point. Tremor and rotation are ignored.