MINI MENTAL STATUS EXAMINATION FORM
Name of Patient: __________________________________________ Date: _____________
DSMR IV TR Diagnosis/Impression: ______________________________________________
Age: ____ Gender: ______ Civil Status: _____ Attending Physician: ____________________
Areas of Mental Function Maximum Actual Evaluation Activity
Evaluated Score Score
Orientation to Time 3 May ask:
What day is today?
What month is it today?
What year is today?
Orientation to Place 1 May ask:
Where are you now?
Attention and Immediate 3 May ask:
Recall Repeat these words now, bell,
book, and candle (1 point per word)
Remember the words and I will ask
you to repeat them in few minutes
Abstract Thinking 3 May ask:
a. What does the saying “No use
of crying over spilled milk”?
Recent Memory 3 May ask:
b. Say three words I asked you to
remember earlier
Naming Objects 2 Point to any object example “eyeglasses”
and ask what is this? Repeat with other
item. (2 points possible)
Ability to follow simple 2 May ask:
verbal commands c. Tear this paper in one half and
throw it in the trash can
Ability to follow simple 2 Write a command on a piece of paper (e.g.
written commands Touch your nose), give the paper to the
patient and say “Do what it says on this
paper. (1 point for correct action)
Ability to use language 3 Ask the patient to write a sentence (3
correctly points if sentence has a subject, a verb,
and has a valid meaning)
Ability to concentrate 4 “Say the month of the year in reverse,
starting with December.” (1 point each for
every correct answers from November
through August, 4 points possible)
Understanding spatial 5 Draw a clock; put in all the numbers; and
relationships set the hands on 3 o’clock. (clock circle- 1
point; numbers in correct sequence- 1
point; numbers placed on clock correctly- 1
point; two hands on the clock- 1 point
hands set at correct time- 1 point) (5
points possible)
Total Score
Scoring: 21-30 – normal; 11-20 – mild cognitive impairment; 0-10 – severe cognitive impairment
Assessed by: _____________________________ Date: _____________ Time: ____________
COMPREHENSIVE MENTAL STATUS
EXAMINATION
Patient’s Name: ______________________________________ Date: _____________
Age: _____ Gender: _____ Status: _________
DSMR IV TR Diagnosis/Impression: ___________________________________________
Attending Physician: ________________________________ Ward: ________________
I. Presentation
A. General Appearance
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
B. General Mobility
a. Posture and Gait:
b. Activity
i. Normoactive
ii. Psychomotor Retardation
iii. Hyperactive
iv. Agitated
c. Behavior
Friendly Impulsive Angry Embarrassed Negativistic
Evasive Seclusive Indifferent Withdrawn
d. Nurse Patient Interaction
Cooperative
Uncooperative
Initially All Throughout
e. Quality
Warm Distant Hostile Suspicious
Talkative Dependent
Others: ____________________________________________
C. Speech Patterns
a. Character
Spontaneous Deliberate Pressured Blocking
b. Organization of Talk
Relevant Loose Association Tangentiality Irrelevant
Flight of Ideas Neologism Others: ___________________
c. Accessibility
Good Self Absorbed Defensive Fair
Mute Inaccessible
D. Emotional State and Reaction
1. Mood
Euthymic Depressed Euphoric Labile Irritable
Guilty Anxious Fearful Sad Despairing
2. Affect
Appropriate Inappropriate
3. Quality
Flat Blunt Restricted Labile
4. Rate of Mood (1-10) _________
5. Describe: _________________________________________________________
____________________________________________________________________
____________________________________________________________________
E. Thought Content
Central Theme; What is important to the client?
________________________________________________________________________
__________________________________________________________________
Self-Concept; How does the client view himself or herself?
_____________________________________________________________________
_____________________________________________________________________
Delusion?
Type: ________________________________________________________________
_____________________________________________________________________
Suicidal or Homicidal Ideas
_____________________________________________________________________
_____________________________________________________________________
Preoccupation and Rumination
_____________________________________________________________________
_____________________________________________________________________
Obsessions/Paranoia/Phobias/Ritual
_____________________________________________________________________
_____________________________________________________________________
Perceptual Disturbances
i. Hallucinations: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ii. Depersonalizations or Derealizations: ____________________________________
_____________________________________________________________________
iii. Illusions: ___________________________________________________________
iv. Others: ____________________________________________________________
F. Neurovegetative Functions
a. Sleep
Normal Insomnia Hypersomnia
b. Appetite: ___________________________________________________________
c. Diurnal Variation: ____________________________________________________
d. Weight: ___________________________________________________________
e. Libido: ____________________________________________________________
G. General Sensorium and Intellectual Status
A. Orientation
i. Time: __________________________________________________________
ii. Person: ________________________________________________________
iii. Place: _________________________________________________________
iv. Level of Consciousness: ___________________________________________
_________________________________________________________________
v. Calculation: _____________________________________________________
_________________________________________________________________
vi. Concentration: __________________________________________________
_________________________________________________________________
vii. General Information: _____________________________________________
_________________________________________________________________
viii. Abstract Thinking: _______________________________________________
__________________________________________________________________
__________________________________________________________________
ix. Judgment: _______________________________________________________
__________________________________________________________________
__________________________________________________________________
x. Memory:
1. Immediate: ______________________________________________________
__________________________________________________________________
2. Recent: _________________________________________________________
__________________________________________________________________
3. Remote: _________________________________________________________
__________________________________________________________________
xi. Insight: _________________________________________________________
__________________________________________________________________
xii. Adaptive Use of Coping/Ego Mechanisms: ____________________________
__________________________________________________________________
__________________________________________________________________
Assessed by: ___________________________________ Date: ___________ Time: _________
