NAME: MONTREAL COGNITIVE ASSESSMENT (MOCA) Education : Date of birth : Version 7.3 Alternative Version Sex: DATE: Pe ena O Draw CLOCK (Ten past nine) POINTS Copy cylinder (3 pois) {1 tJ Contour Numbers WENA 222d list of words, subject must TRAIN EGG HAT CHAIR | BLUE repeat them.Do 2trials,evenif Ist tralissuccessful TSealal Do a recall after 5 minutes. 2nd trial points| Pe PERERA Reacistofcigns 1 aignzsecy, Subject hasto epeat them inthe foward order 1 ‘Subject has to repeat them in the backward order 174 /2 Read lst of letters. The subject must tap with his hand at each letter A. No pointsif > 2 erors L_] FBACMNAAJKLBAFAKDEAAAJAMOFAAB | —/1 Serial 7 subtraction starting at 80 (173 [166 (159 [152 (145 ors correct subtractions:_3 pts,20r3 correct: 2 pts, 1 correct 4 peo correct: O pt irra Repeat: She heard his lawyer was the one to sue after the accident. [ ] The litle girls who were given too much candy got stomach aches. [1 i EUASCMME Similarity beweeneg.banana-orange=fruit [ ]eye-ear [_ ] trumpet=piano Fluency / Name maximum number of words in one minute that begin with the letter B ] (N211 words) TRAIN | EGG HAT | CHAIR] BLUE | Pomistor uNcuED O recall only psi ae Has to recall words witanocue | [1] ul 1 o category cue Optional ‘Multiple choice cue ORIENTATION [MMIC [ ] Month = [ ] Year [ 1 Day [ Iplace [I city | ‘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