Patient Name: __________________ Rater: ____________________ Date: Activity Feeding 0 = unable 5 = needs help cutting, spreading butter, etc.

, or requires modified diet 10 = independent Bathing 0 = dependent 5 = independent (or in shower) Grooming 0 = needs to help with personal care 5 = independent face/hair/teeth/shaving (implements provided) Dressing 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) Bowels 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent Bladder 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent Toilet Use 0 = dependent 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping) Transfers (bed to chair and back) 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent Mobility (on level surfaces) 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 = independent (but may use any aid; for example, stick) > 50 yards Stairs 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent TOTAL (0 - 100)

: Score

10

10

10

10

10

10

15

10

15

10

________

Instruction: Please give one point for each correct response within each question or activity. Approach the patient with respect and encouragement. Ask: Do you have trouble with memory? ( ) Yes (/) No May I ask some questions about memory? ( /)Yes ( ) No

(5)TIME ORIENTATION Ask: What is the year? Season? Month? Date? Day? (5) PLACE ORIENTATION Ask: Where are we now? Country? City? Cottage No? Province? (3) REGISTRATION OF THREE WORDS The examiner names three unrelated objects clearly and slowly, then the instructor asks the patient to name all three of them. The patients response is used for scoring. The examiner repeats them until patient learns all of them, if possible. (5) TEST OF ATTENTION AND CALCULATION I would like you to count backwards from 100 by sevens. (93, 86, 79, 72, 65) Alternative: Spell WORLD backwards. (D-L-R-O-W) (3) RECALL OF THREE WORDS Earlier I told you the names of three things. Can you tell me what those were? (2) NAMING Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them. (1) REPETITION Repeat the phrase: No ifs ands, or buts (3) COMPHREHENSION Take the paper in your right hand, fold it in half, and put it on the floor. (The examiner gives the patient a piece of blank paper). (1) READING Please read this and do what it says. (Written instruction is: Close your eyes) (1) WRITING Make up and write a sentence about anything. (This sentence must contain a noun and a verb) (1) DRAWING Please copy this picture. (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and to must intersect.)