| Item | Scoring | Weight | Score |
| What year is it now? | 0 or 1 (Score 1 if correct, 0 if incorrect) |
x2 | |
| What month is it? | 0 or 1 (Score 1 if correct, 0 if incorrect) |
x2 | |
| Repeat phrase and remember: "John Brown, 42 Market Street, New York" | |||
| About what time is it? (answer correct if within one hour) | 0 or 1 (Score 1 if correct, 0 if incorrect) |
x2 | |
| Count backwards from 20 to 1 | 0, 1, or 2 (Score 2 if correct, 1 if 1 error, and 0 if 2 or more errors) |
x1 | |
| Say the months in reverse | 0, 1, or 2 (Score 2 if correct, 1 if 1 error, and 0 if 2 or more errors) |
x1 | |
| Repeat memory phrase | 0, 1, 2, 3, 4, 5 (Score 5 if correct; deduct 1 for each miss) |
x1 | |
| Final score is sum of the total; score less than 15 suggests the presence of altered cognition and need for further assessment. | |||