mini mental status format.docx

Mini mental status examination format

1. Ms. Pooja Sen
Nursing lecturer (MHN)
PSYCHIATRIC HISTORY TAKING
I. PRELIMINARY DATA:
Name :
Age :
Sex :
Education :
Marital status :
Occupational status :
Income :
Religion :
Address :
Diagnosis :
Name of the informant :
Relationship with the patient:
INFORMANT AND RELIABILIT Y
II. CHIEF COMPLAINTS WITH DURATION
a) According to patient
b) According to the patient relatives / Secondary sources.
III. HISTORY OF THE PRESENT ILLNESS(HOPI)
Onset:
Duration:
Course:
Intensity:
Precipitating factor:
History of chronological description of psychiatric problem, biological functioning
PAST PSYCHIATRIC HISTORY:
PAST MEDICAL HISTORY:
FAMILY STRUCTURE / TREE
Type of family-
Support system-
History of illness in family
PERSONAL HISTORY
PERINATAL HISTORY:
CHILDHOOD HISTORY:

2. Ms. Pooja Sen
Nursing lecturer (MHN)
EDUCATIONAL HISTORY
PLAY HISTORY
PUBERTY HISTORY
OCCUPATIONAL HISTORY
SEXUAL HISTORY
MARITAL HISTORY
PREMORBID PERSONALITY
FANTASY LIFE:
HABITS:
- Eating pattern :
- Elimination :
- Sleep :
- Exercise pattern :
- Use of drug, tobacco, alcohol:

MINI MENTAL STATUS EXAMINATION
SNO PATIENT’S INSTRUCTION MAX
SCORE
PATIENT
SCORE
1.


ORIENTATION (TIME)

a) Student : Which year are we in?
Patient :

b) Student : Which month is this?
Patient :

c) Student : What is the date today?
Patient :

d) Student : Which day of the week is today?
Patient :

e) Student : What is the time now?
Patient :






1


1



1


1


1

3. Ms. Pooja Sen
Nursing lecturer (MHN)

ORIENTATION (PLACE)

a) Student : Which country are we in?
Patient :

b) Student : Which is our state?
Patient :

c) Student : Which city are you in now?
Patient :

d) Student : Which place is this?
Patient :

e) Student : Which floor is this?
Patient :



1

1


1

1

1














2.


ATTENTION AND CALCULATION
Student : Begin with 100 and count backwards by
7. Stop after 5
Subtractions. Score the correct
subtractions
Patient:





5






3.

IMMEDIATE RECALL (REGISTRATION)

Student : Ask the patient to recall ……..
………….. ………………….
Patient : …….….. …………… ……………



3





4.

LANGUAGE AND MOTOR (NAMING)
Student : EX.- Pen and notebook were shown to
the patient and asked him what it was?
Patient :



2





5.

DELAYED VERBAL RECALL

Student : EX.- Asked the patient to recall the three
words you previously
asked him to remember.
Patient:



3

4. Ms. Pooja Sen
Nursing lecturer (MHN)

6.

REPITITION
Student : EX.- Ask the patient to repeat ‘Pet me
chuhe kudna”.
Patient:



1





7.

THREE STAGE COMMAND
Student : EX. - Give the individual a plain piece of
paper and say- Take the
paper in your hand , fold it in half and
put it on the floor.
Patient:



3





9

READING
Student: EX.- I wrote “apne bhai se hello kro” in
large letters and shown
it to patient and asked him to read the
message and do accordingly.
Patient:



1





10

WRITING
Student : EX- A piece of paper was given to the
patient and he was asked to Write a sentence of his choice.
Patient:



1





11

COPYING
Student : Ask the patient to copy the figure.








Patient:






1




TOTAL SCORE OF MMSE


30

29

5. Ms. Pooja Sen
Nursing lecturer (MHN)
INTERPRETATION OF MMSE SCORE

Total score of the patient:

Reference ranges:
25-30- normal cognitive function
19-24-mild cognitive impairment
10-18- moderate cognitive impairment
≤9 - severe cognitive impairment

SUMMARY OF MMSE