2015 COGNISTAT ACTIVE FORM

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2015 COGNISTAT ACTIVE FORM
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Jan 1, 2013
0
First Name
Family Name
Yrs
Name: _______________________________
Gender: _______
Date of birth: ____________
Educ: ______
mmm dd, yyyy
City:
_________________________
1 Yrs
Age: ______
Current occupation:_________________
Lang:
English
______________
Nature of last job: ___________
L
R
Handedness:
(click)
Date last worked:___________
mmm dd, yyyy
Reason for hospitalization or visit to clinic:
__________________________
Date of injury:
___________
if any
Date of testing: __________ Time: ______ Inpatient:
Past Medical History
Outpatient: ✔
Location: ___________________
1._________________________________________________
2._________________________________________________
3._________________________________________________
4._________________________________________________
Past Psychiatric History
1._________________________________________________
2._________________________________________________
3._________________________________________________
4._________________________________________________
Factors Potentially Influencing Test Performance
(Check Y or N for each item)
?
Y
Comments
?
N
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
____________________
________________________
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Page 1 of 8
First Name
This form no longer valid after
Jan 31, 2016
LEVEL OF CONSCIOUSNESS:
I.
Alert
?
Lethargic
Fluctuating
_________________________________________________________________________________
II. ORIENTATION
A. Person
Correct
Other Response
Incorrect
1. What is your full name?
0
2. What is your present age?
0
B. Place
?
1. Where are you right now?
0
?
2. What city are we in?
0
1. What is the year?
0
2. What month is it?
0
3. What day of the week is it?
0
4. What is the date?
0
5. What time is it?
0
C. Time
?
?
?
0
Total Score _________
III. ATTENTION
?
A. Digit Repetition
Other Response
?
?
Y
Pass
Screen: 8-3-5-2-9-1
________________________
Fail
Metric:
Discontinue after two misses at any level.
N
Y
Y
N
N
Y
N
3-7-2
0
5-1-4-9
0
8-2-5-3-9
0
2-8-5-1-6-4
0
4-9-5
0
9-2-7-4
0
6-1-7-3-8
0
9-1-7-5-8-2
0
Total Score _________
0
Other Responses
_
Cognistat Inc. © 2015
First Name
Page 2 of 8
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
✔
B
2nd
or C
3rd
4th
5th
6th
7th
Incorrect Answers
8th
Robin
___________________________
Carrot
___________________________
Piano
___________________________
Green
___________________________
IV. LANGUAGE
?
A. Speech Sample: Fishing Picture
Record patient’s 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.
0
__________________________________
b. Point to the floor.
0
__________________________________
c. Hand me the keys.
0
__________________________________
d. Point to the pen and pick up the keys.
0
__________________________________
e. Hand me the paper and point to the coin.
0
__________________________________
f. Point to the keys, hand me the pen, and
pick up the coin.
0
__________________________________
Total Score
Cognistat Inc. © 2015
First Name
0
_______
Page 3 of 8
C. Repetition
?
Pass
Screen: The beginning movement revealed the composer’s 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.
0
___________________________
b. He swam across the lake.
0
___________________________
c. The winding road led to the village.
0
___________________________
d. He left the latch open.
0
___________________________
e. The honeycomb drew a swarm of bees.
0
___________________________
f. No ifs, ands or buts
0
___________________________
Total Score
0
__________
D. Naming
?
Screen
Y
a) Pen
Y
N
N
b) Cap or Top
Y
Y
N
c) Clip
d) Point, Tip, or Nib
Fail
Pass
?
N
Metric: (If incorrect, record response)
Y
Other Response
N
Other Response
Y
a. Shoe
0
__________________
e. Horseshoe
b. Bus
0
__________________
f. Anchor
c. Ladder
0
__________________
d. Kite
0
__________________
N
0
__________________
0
__________________
g. Octopus
0
__________________
h. Xylophone
0
__________________
_
0
Total Score _________
Cognistat Inc. © 2015
First Name
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)
Y
N
0
1. Design
0
2. Design
0
3. Design
0
Total Score _________
?
VI. MEMORY
Four Word Memory Test (Part 2)
Click Box for Elapsed Time
Time (Mins)
Answers can be recalled without prompting,
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
0
Carrot
Vegetable
Carrot, potato, onion
0
Piano
Musical Instrument
Violin, guitar, piano
0
Green
Color
Red, green, yellow
0
Other Responses
Total Score
Cognistat Inc. © 2015
First Name
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)
Y
Response
N
How much is 5 + 3?
___________
0
How much is 15 + 7?
___________
0
How much is 31 - 8?
___________
0
How much is 39 ÷ 3?
___________
0
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 abstract—only “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
0
b. Bicycle-Train
Transportation
0
c. Watch-Ruler
Measurement
0
d. Corkscrew-Hammer
Tools
0
________________________________
________________________________
________________________________
________________________________
0
Total Score _________
Cognistat Inc. © 2015
First Name
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 o’clock?
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. Patient’s 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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First Name
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†
Age:
Date of Exam:
Yrs. of Educ:
Date Last Worked:
Name: First Name
Occupation:
Average Range
Mild Impairment
Moderate Impairment
Severe Impairment
0
0
0
0
0
0
0
0
0
0
† 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
Rev 30.99
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