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013 COGNISTAT$&7,9()250

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0 Yrs
First Name
Family Name
Jan 1, 2013
Enter
Name: _______________________________
Gender: _______
Date of birth: ____________
Educ: ______
mmm dd, yyyy

City:

_________________________

Yrs
Age: ______

Current occupation:_________________

Lang:

English
______________

Nature of last job: ___________

Handedness:

(click)

Date last worked:___________

mmm dd, yyyy

Reason for hospitalization or visit to clinic:

__________________________

Date of injury:

___________
if any

3:47 pm Inpatient:
Nov 12, 2013
Date of testing: __________
Time: ______

Past Medical History

Outpatient:

Location: ___________________

1._________________________________________________
2._________________________________________________
3._________________________________________________

EXPIRED

4._________________________________________________

Past Psychiatric History

1._________________________________________________

2._________________________________________________
3._________________________________________________
4._________________________________________________

Factors Potentially Influencing Test Performance

(Check Y or N for each item)

Comments

CNS-Active Medications, Dosage

and Frequency, Check if None

Neurological Condition

____________________

________________________

Visual Impairment

____________________

________________________

Hearing Loss / Tinnitus

____________________

________________________

Dizziness / Vertigo

____________________

________________________

Pain

____________________

________________________

Substance Abuse

____________________

________________________

Sleep Deprivation / Insomnia

____________________

________________________

Poor Cooperation

____________________

________________________

Psychiatric Disorder

____________________

________________________

Fatigue

____________________

________________________

English as a 2nd Language

____________________

________________________

Learning Disorder

____________________

________________________

ADHD

____________________

________________________

Litigation

____________________

________________________

Cognistat Inc. 2013

Nov 12, 2013

This form no longer valid after Oct 31, 2013

3:47 pm

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LEVEL OF CONSCIOUSNESS:

I.

Alert

Lethargic

Fluctuating

_________________________________________________________________________________

II. ORIENTATION
A. Person

Correct

Other Response

Incorrect

1. What is your full name?

2. What is your present age?

B. Place
?

1. Where are you right now?

2. What city are we in?

1. What is the year?

2. What month is it?

3. What day of the week is it?

4. What is the date?

5. What time is it?

C. Time
?

0
Total Score _________

III. ATTENTION
?

A. Digit Repetition
Other Response
?

Pass

Screen: 8-3-5-2-9-1

________________________

Fail

Metric:

Discontinue after two misses at any level.

3-7-2

5-1-4-9

8-2-5-3-9

2-8-5-1-6-4

4-9-5

9-2-7-4

6-1-7-3-8

9-1-7-5-8-2

Total Score _________

0

Other Responses

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Show

Option

Hide

Click to display optional 7, 8 and 9 digit sequences, which can be used for additional qualitative information only.

B. Four Word Registration (Part 1)

Give the four words (from group A, B or C) until the patient is able to repeat all
four words on two sucessive trials. Click if correct and record incorrect answers.
The Clock starts automatically when registration is complete.
Clock

Select Word Group A,

1st

2nd

or C

3rd

4th

5th

6th

7th

Incorrect Answers

8th

Robin

___________________________

Carrot

___________________________

Piano

___________________________

Green

___________________________

IV. LANGUAGE
?

A. Speech Sample: Fishing Picture

Record patients response verbatim.

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Examiner's Comments: ________________________________________________________________________

B. Comprehension

Place a pen, some keys, a coin, an index card and three other
objects (e.g. paper clip, rubber band, etc.) in front of the patient.

Screen: 3-step command: Turn over the paper, hand me the pen, and point to your nose.
Pass

Fail

Other Response

Metric
Correct

Incorrect

a. Pick up the pen.

__________________________________

b. Point to the floor.

__________________________________

c. Hand me the keys.

__________________________________

d. Point to the pen and pick up the keys.

__________________________________

e. Hand me the paper and point to the coin.

__________________________________

f. Point to the keys, hand me the pen, and

pick up the coin.

__________________________________
Total Score

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3:47 pm

0
_______
Page 3 of 8

C. Repetition
?

Pass

Screen: The beginning movement revealed the composers intention.

Fail

____________________________________________________________________________________

Metric:

Patient may make two attempts to repeat the statement.

1st Attempt
Correct

2nd Attempt
Correct

Other Response

Incorrect

a. Out the window.

___________________________

b. He swam across the lake.

___________________________

c. The winding road led to the village.

___________________________

d. He left the latch open.

___________________________

e. The honeycomb drew a swarm of bees.

___________________________

f. No ifs, ands or buts

___________________________
Total Score

0
__________

D. Naming
?

Screen
Y

a) Pen

b) Cap or Top

c) Clip

d) Point, Tip, or Nib

Fail

Pass
?

Metric: (If incorrect, record response)

Y

Other Response

Other Response
Y

a. Shoe

__________________

b. Bus

__________________

f. Anchor

c. Ladder

__________________

d. Kite

__________________

e. Horseshoe

__________________

__________________

g. Octopus

__________________

h. Xylophone

__________________

0
Total Score _________
Cognistat Inc. 2013

Nov 12, 2013

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Page 4 of 8

V. CONSTRUCTIONS
?

Screen: Visual Memory

Present stimulus sheet for 10 seconds, then have patient draw the two figures from memory. Must be
perfect to pass. The examiner may wish to have patients who fail the screen to copy the two figures.

Pass
?

Metric: Tile Designs

Fail

Present the tiles and click the boxes to start and stop the timers.
Click Y or N for correct. Scores are automatically calculated.

Place tiles in front of patient as

shown here:

Start

Stop

Time (secs)

1. Design

2. Design

3. Design

0
Total Score _________

VI. MEMORY

Four Word Memory Test (Part 2)

Click Box for Elapsed Time

Answers can be recalled without prompting,

Time (Mins)

or recalled with category prompt,

or recognized only from a list.

Words

Category

Recognition
Category
Correct

Word
Correct

Recognition
Correct

Incorrect

Robin

Bird

Sparrow, robin, bluejay

Carrot

Vegetable

Carrot, potato, onion

Piano

Musical Instrument

Violin, guitar, piano

Green

Color

Red, green, yellow

Other Responses

Total Score
Cognistat Inc. 2013

Nov 12, 2013

3:47 pm

0
__________
Page 5 of 8

VII. CALCULATIONS
Screen:

Pose the math question and start the timer. Stop the timer when answered. Enter the
response. Click on Y or N. Scoring is automatic. Must be correct in 20 secs or less .
Start

Response

Stop

Time (secs)

How much is 5 x 13?

________

Pass
Metric:

Fail

Problems may be repeated but time runs continously from first presentation.

Start

Stop

Time (secs)

Response

How much is 5 + 3?

___________

How much is 15 + 7?

___________

How much is 31 - 8?

___________

How much is 39 3?

___________

0
Total Score _________

VIII. REASONING
A. Similarities:

Explain: A hat and coat are alike because they are both articles of clothing.
If patient does not respond, encourage; if patient gives differences, score 0.

Screen: Painting & Music

(Must be abstractonly art, artist, or forms of art are acceptable.)

Pass

Fail

____________________________________________________________________________________

Metric:

Answers are correct if fully abstract; imprecise if

concrete; or incorrect. See Manual for examples.

Correct

Abstract Idea

Imprecise

Other Responses

Incorrect

a. Rose-Tulip

Flowers

b. Bicycle-Train

Transportation

c. Watch-Ruler

Measurement

d. Corkscrew-Hammer

Tools

________________________________
________________________________
________________________________
________________________________

0
Total Score _________
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Nov 12, 2013

3:47 pm

Page 6 of 8

B. Judgment
?

Screen: What would do if you were stranded in an airport 1,000 miles from home, with only $1.00 in your pocket?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Pass
?

Metric:

Fail

Score as correct, partially correct or incorrect.

a. What would you do if you woke up one minute before 8:00 a.m. and remembered
that you had an important appointment downtown at 8:00 oclock?

Correct

Partial

Incorrect

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

b. What would you do if you were walking beside a lake and saw that a
two year old child was playing alone at the end of a pier?

Correct

Partial

Incorrect

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

c. What would you do if you came home and found that a broken
pipe was flooding the kitchen?

Correct

Partial

Incorrect

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

0
Total Score _________

IX. Patients Comments

Record patient's response verbatim

Was there anything that distracted you today or made it hard to concentrate?
___________________________________________________________________________________________________________________

How do you feel you did on the questions today?

___________________________________________________________________________________________________________________

X. Examiner's
Observations
(re: attitude, fatigue, cooperation, awareness, irritability, etc.)

(see p 29 of the 2013 Cognistat Manual)

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Generate Summary
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Nov 12, 2013

3:47 pm

Page 7 of 8

XI. Cognistat Summary

Orientation:

Attention:

Language:

Constructions:

Memory:

Summary:

MCI Index: The MCI Index is designed to provide guidance regarding diagnostic questions of mild cognitive impairment or dementia. It is
(0 to 6)

ON

not intended for use in cases with isolated and more specific cognitive deficits such as amnestic or aphasic disorders.

OFF

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Cognitive Status Profile

Name:

Age:

Occupation:

Yrs. of Educ:

Date of Exam: Nov 12, 2013

Date Last Worked:

Average Range

EXPIRED

Mild Impairment

Moderate Impairment

Severe Impairment

THE VALIDITY OF THIS EXAMINATION DEPENDS ON ADMINISTRATION IN STRICT ACCORDANCE WITH THE 2013 COGNISTAT MANUAL.

Note: Normal scores cannot be taken as evidence that brain pathology does not exist. Similarly, scores falling in the mild, moderate
or severe range of impairment do not necessarily reflect brain dysfunction (see section of the Cognistat Manual entitled Cautions in Interpretation).
Copyright 1983, 1988, 1995, 2001, 2007, 2009, 2010, 2011 and 2013. No portion of this test may be copied,
duplicated or otherwise reproduced without the prior written consent of the copyright owner.
Cognistat Inc., Headquarters: 4480 Cte de Liesse, Suite #355, Montreal, QC, H4N 2R1 Canada
Phone: +1-(514)-337-7337 Fax: +1-(514)-336-6537 Web: www.cognistat.com
California office: PO Box 460, Fairfax, CA 94978 Phone:+1-800-922-5840
Cognistat Inc. 2013

Rev 30.9

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