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Patient ID
MMSE
Total Score: 0
Time and Place
Season
Year
Month
Date of month
Day of week
State
County
City
Office
Floor
Repeat 3 items
Apple
Table
Umbrella
Spell HOUSE backward, or Serial 7
E or 100-7
S or 93-7
U or 86-7
O or 79-7
H or 72-7
Recall 3 items
Apple
Table
Umbrella
Name 2 items and repeat
Name pencil
Name watch
Repeat No ifs ands nor buts
Follow 3 steps command
Take this paper in right hand
fold it in half
place it on floor
Follow written command, Write, and copy design
close your eyes
Write a sentence
Copy design
Notes