QUESTION |
RESPONSE |
INCORRECT RESPONSES |
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1. What are the date, month, and year? |
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2. What is the day of the week? |
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3. What is the name of this place? |
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4. What is your phone number? |
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5. How old are you? |
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6. When were you born? |
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7. Who is the current president? |
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8. Who was the president before him? |
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9. What was your mother’s maiden name? |
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10. Can you count backward from 20 by 3’s? |
Click to download as a fillable PDF
Scoring*
0-2 errors: normal mental functioning
3-4 errors: mild cognitive impairment
5-7 errors: moderate cognitive impairment
8 or more errors: severe cognitive impairment
Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41.
