This document contains a cognitive assessment form for an individual named First Name. It collects information on their demographic details, medical history, potential factors influencing performance, and results on tests of level of consciousness, orientation, attention, language, memory, reasoning, and calculations. The form is used to generate a cognitive status profile summarizing their performance in key areas such as orientation, memory, attention and language.

1. 2015 COGNISTAT ACTIVE FORM
Name: _______________________________ Gender: _______ Date of birth: ____________ Educ: ______
City: _________________________ Age: ______ Lang: ______________ Handedness: (click)
Current occupation:_________________ Nature of last job: ___________ Date last worked:___________
Reason for hospitalization or visit to clinic: __________________________ Date of injury: ___________
Date of testing: __________ Time: ______ Inpatient: Outpatient: Location: ___________________
Past Medical History 1._________________________________________________
2._________________________________________________
3._________________________________________________
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 ____________________ ________________________
Cognistat Inc. © 2015 Page 1 of 8
Litigation ____________________ ________________________
Valid 10Days
Press to Start ? Reset Form
Hold down left mouse key on any "?" for contextual help
First Name Family Name Enter Jan 1, 2013
Yrs
Yrs0
1
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English
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First Name
L R
Y N
mmm dd, yyyy
if any
mmm dd, yyyy
This form no longer valid after Jan 31, 2016

2. Cognistat Inc. © 2015 Page 2 of 8
I. LEVEL OF CONSCIOUSNESS:
Alert Lethargic Fluctuating
II. ORIENTATION
Other ResponseA. Person
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?
C. Time
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?
Total Score _________
A. Digit Repetition
Other Response
Screen: 8-3-5-2-9-1 Pass Fail ________________________
III. ATTENTION
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0
0
? 0
? 0
0
?
First Name
?
0
0
0
0
0
? Metric:
_________________________________________________________________________________
Total Score _________
_
Discontinue after two misses at any level.
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
Correct
Y N Y N Y N Y N
6-1-7-3-8 0 9-1-7-5-8-2 0
Other Responses
Incorrect
0
Y N

3. Cognistat Inc. © 2015 Page 3 of 8
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.
1st
2nd
3rd
4th
5th
6th
7th
8th Incorrect Answers
A. Speech Sample: Fishing Picture Record patient’s response verbatim.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________
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
Metric Other Response
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 _______
Option Click to display optional 7, 8 and 9 digit sequences, which can be used for additional qualitative information only.
?
Select Word Group A, B or C
First Name
___________________________
___________________________
___________________________
___________________________
Show Hide
0
?
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?
?
Robin
Carrot
Piano
Green
IV. LANGUAGE
Examiner's Comments:
0
0
0
0
Correct Incorrect
Clock
0
0

4. Cognistat Inc. © 2015 Page 4 of 8
C. Repetition
Screen: The beginning movement revealed the composer’s intention.
____________________________________________________________________________________
Pass Fail
Metric: Patient may make two attempts to repeat the statement.
Other Response
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 __________
D. Naming
Screen
a) Pen b) Cap or Top c) Clip d) Point, Tip, or Nib
Metric: (If incorrect, record response)
Other Response Other Response
a. Shoe __________________ e. Horseshoe __________________
b. Bus __________________ f. Anchor _ __________________
c. Ladder __________________ g. Octopus __________________
d. Kite __________________ h. Xylophone __________________
Total Score _________
?
?
Y N Y N
First Name
1st Attempt
Correct
2nd Attempt
Correct
Y N Y N Y N Y N
Pass Fail
Incorrect
?
?
0
0
0
0
0
0
0
0 0
0 0
0 0
0 00
0

5. Cognistat Inc. © 2015 Page 5 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 Fail
Metric: Tile Designs
Present the tiles and click the boxes to start and stop the timers.
Click Y or N for correct. Scores are automatically calculated.
1. Design
2. Design
3. Design
Total Score _________
VI.MEMORY Four Word Memory Test (Part 2)
Answers can be recalled without prompting,
or recalled with category prompt,
or recognized only from a list.
Words Category Recognition
Total Score __________
Place tiles in front of patient as
shown here:
?
?
Y N
?
0
First Name
Time (Mins)
Start Stop
Click Box for Elapsed Time
0
00
0
0
Robin Bird Sparrow, robin, bluejay 0
Carrot Vegetable Carrot, potato, onion 0
Piano Musical Instrument Violin, guitar, piano 0
Green Red, green, yellowColor 0
Word
Correct
Category
Correct
Recognition
Correct
Incorrect
Other Responses
Time (secs)

6. Cognistat Inc. © 2015 Page 6 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 .
Response
How much is 5 x 13?
Pass Fail
Metric: Problems may be repeated but time runs continously from first presentation.
Response
How much is 5 + 3?
How much is 15 + 7?
How much is 31 - 8?
How much is 39 ÷ 3?
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.
Abstract Idea Other Responses
a. Rose-Tulip Flowers
b. Bicycle-Train Transportation
c. Watch-Ruler Measurement
d. Corkscrew-Hammer Tools
Total Score _________
Start Stop
?
?
Start Stop
Y N
?
?
First Name
________
___________
___________
___________
___________
________________________________
________________________________
________________________________
Time (secs)
Time (secs)
0
0
0
0
0
0
0
0
0
0
________________________________
Correct Imprecise Incorrect

7. Cognistat Inc. © 2015 Page 7 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 Fail
Metric: 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?
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?
c. What would you do if you came home and found that a broken
pipe was flooding the kitchen?
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 (see p 29 of the 2013 Cognistat Manual)
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First Name
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
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Correct Partial Incorrect
Correct Partial Incorrect
Correct Partial Incorrect
0
_____________________________________________________________________________________________________________
(re: attitude, fatigue, cooperation, awareness, irritability, etc.)
?
Generate Summary

8. Cognitive Status Profile†
† 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 Page 8 of 8
XI. Cognistat Summary
Orientation:
Constructions:
Memory:
Summary:
MCI Index:?
ON OFF
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.
Print Report Print Entire Exam E-MAIL Save File
Name: First Name Age: Date of Exam:
Occupation: Yrs. of Educ: Date Last Worked:
Average Range
Mild Impairment
Moderate Impairment
Severe Impairment
0 0 0 0 0 0 0 0 0 0
Rev 30.99
(0 to 6)
Attention:
Language:
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