2015 COGNISTAT FIVE

Valid 10 Days
2015 COGNISTAT FIVE
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Yrs
0
Jan 1, 2013
Enter
First Name
Family Name
Name: _______________________________
Gender: _______
Date of birth: ____________ Educ: ______
mmm dd, yyyy
2 Yrs
City: __________________________________ Age: ______
MEMORY REGISTRATION
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Select Word Group A
✔
B
English
Native Language: _____________________
Give the four words (from group A, B or C) until the patient
is able to repeat all four words on two successive trials.
or C
Robin
Carrot
Piano
Green
ORIENTATION
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Correct
Incorrect
1. What is your full name?
0
2. What is your present age?
0
?
3. Where are you right now?
0
?
4. What city are we in?
0
5. What is the year?
0
6. What month is it?
0
?
7. What day of the week is it?
0
?
8. What is the date?
0
?
9. What time is it?
0
CONSTRUCTIONS
Tile Designs
0
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)
Y
N
1. Design
0
2. Design
0
3. Design
0
0
Total Score _________
First Name
Cognistat Inc. © 2015
This form no longer valid after Jan 31, 2016
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MEMORY RECALL
Words
:RUGs can be Drecalled without promptingEUHFDOOHG
with Dcategory SURPSWRUFrecognized from a list.
Category
Word
Correct
Recognition
Incorrect
Recognition
Category
Correct
Correct
Robin
Bird
Sparrow, Robin, Bluejay
0
Carrot
Vegetable
Carrot, Potato, Onion
0
Piano
Musical Instrument
Violin, Guitar, Piano
0
Green
Color
Red, Green, Yellow
0
Finish
0
Total Score _________
Memory
Registration:
Orientation:
Average Range
12
Mild Impairment
11
10
9
8
Moderate Impairment
7
6
Severe Impairment
5
4
3
2
1
Constructions:
Average Range
6
Mild Impairment
5
4
Moderate Impairment
3
Severe Impairment
2
1
0
Memory:
12
11
Moderate Impairment
Mild Impairment
Average Range
10
9
8
7
6
Severe Impairment
5
4
3
2
1
? MCI Index: The MCI Index is designed to provide guidance regarding diagnostic questions of mild cognitive impairment or dementia. It is not intended for use in
cases with isolated and more specific cognitive deficits such as amnestic or aphasic disorders.
Normal
0
Possible MCI
Suggests MCI
1
Strongly Suggests MCI
Possible Dementia
3
4
2
E-Mail
Print Report
Suggests Dementia
5
6
Save File
† 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, 2013, 2014 and 2015. 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 Côte 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. © 2015
First Name
Rev 8.92D
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