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OMB # 0925‐XXXX
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IDEAL-Screening Examination
STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized by Public Law 93-296. Rights of study participants are protected
by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for participating or
withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The
information collected in this study will be held in professional confidence. Names and other identifiers will
be separated from information provided and will not appear in any report of the study. Information provided
will be combined for all study participants and reported as statistical summaries.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 90 minutes per response,
including the time for reviewing instructions, searching exiting data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing burden to: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974 ATTN:PRA (0925-xxxx). Do not return the
completed form to this address.
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
First Name:
aft
Last Name:
START PARTICIPANT IN SITTING POSITION
Vital Signs
Blood Pressure
"I will measure your blood pressure 3 times in one arm. You must be relaxed. We should not
talk to each other until all the measurements are taken."
Take the BP measurements, allowing 1 minute between each measurement.
Does participant have any of the following conditions?
Aortic regurgitation
AV shunt left arm
Previous surgery right side
Hyperthyroidism
AV shunt right arm
Previous surgery left side
Systolic
Diastolic
Sitting Measurement #1
Sitting Measurement #2
Sitting Measurement #3
Participant should be standing 1 minute before BP is taken.
dr
A.
Systolic
Diastolic
Left
Right
Standing Measurement
Specify Arm:
If not measured, please state why:
555
666
777
888
999
=
=
=
=
=
555
666
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888
999
Could not do due to physical problems
Could not do due to mental problems
Could not do due to both physical and mental problems
Refused, but theoretically could do
Did not do due to technical problems
1
59451
Screening Protocol ID:
Date Completed:
Tester ID:
/
S C R IDEAL
B.
/ 2 0
Screening Examination
HEENT
1.
Jaeger Vision Test
aft
(*Examiner's note: Hold the Jaeger card approximately 14 - 16 inches from the participant's
eyes, and point to paragraph number 10.)
Say: "I am going to hold up this card a bit more than a foot away from you. When I say 'Go',
I want you to read aloud the lines that I point to. Ready? I want you to read this paragraph
(point to paragraph 10). Go!"
Pass
2.
Fail
Unknown
555
666
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888
999
Whisper Hearing Test
(*Examiner's note: Eliminate as much area noise as possible.)
Ask: "Which of your ears has better hearing?" (Note response on a Post-it, as needed.)
Say: "Starting with your good side, I'm going to stand on that side about an arm's length back
from you, like this (demonstrate positioning). Then I will whisper a combination of letters and
numbers. For example, I might say '4-K-2.' I want you to listen carefully and try to repeat
back the sequence I say to you. If you miss the first time, I will repeat the test one more time
using a different combination of letters and numbers. We will test the ear with better hearing
first and then the other ear. Do you have any questions?"
(*Examiner's note: Stand an arm's length to the side and slightly behind the participant (out of
line-of-sight). If participant doesn't know which ear has better hearing and which has worse,
start by standing to the participant's right ear.)
Say (normal voice): "Ready? Here is the first combination."
dr
(*Examiner's note: Gently exhale. At the end of your exhalation, whisper the first sequence
of letters and numbers. If the patient responds incorrectly, repeat the test one more time
using the second sequence of letters and numbers. After one ear has been tested, repeat this
procedure using the third and fourth sequences with the participant covering his/her other
ear.)
Right Ear:
Pass
Fail
Unknown
555
666
777
888
999
Left Ear:
Pass
Fail
Unknown
555
666
777
888
999
555
666
777
888
999
=
=
=
=
=
Could not do due to physical problems
Could not do due to mental problems
Could not do due to both physical and mental problems
Refused, but theoretically could do
Did not do due to technical problems
2
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Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
C.
/ 2 0
Screening Examination
Chest Auscultation
Loud Heart Murmurs (grade 3 or greater)
555
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888
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aft
1.
Yes
2.
No
Unknown
No
Unknown
999
999
Lungs
a.
Rales
No Rales
b.
Rales at bases
Unknown
555
777
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888
555
777
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999
Wheezing
No Wheezing
Wheezing
Unknown
999
Upper & Lower Extremities
dr
D.
Rubs
Yes
4.
Unknown
Clicks
Yes
3.
No
1.
Extremities Inspection
(*Examiner's Note: If amputation involves only fingers (other than the thumb) or toes
(other than the big toe), do not check.)
Normal
Amputation
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=
=
=
=
=
Paralysis
Paresis
Unknown
555
777
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888
Could not do due to physical problems
Could not do due to mental problems
Could not do due to both physical and mental problems
Refused, but theoretically could do
Did not do due to technical problems
3
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999
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
PARTICIPANT LYING DOWN
2.
Motor Testing
aft
Leg Lift
(*Examiner's note: This test is done with the participant in a supine position.)
Demonstrate and Say: "I want you to lift up your legs by bending your knees at a
right angle. When I say 'Go', I want you hold that position until I tell you to stop."
"Ready? Go!"
Unable to attain position or hold for 1 second
Holds position for less than 5 seconds
Hold position for 5 seconds
Unknown
3.
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Sensory Testing
(*Examiner's note: Test one foot at a time while the participant is in a supine position.)
Show Filament and Say: "I am going to use this plastic filament to touch different areas on
the inside of your ankle. I want you to tell me as soon as you feel the contact. First, I will
test your right ankle, and then your left."
"Ready? Please close your eyes."
dr
(*Examiner's note: using the monofilament administer at least 3 touches and a couple of
fakes of the participant's internal ankle ( e.g., the internal or medial malleolus)
a.
Probing Touch
Right Ankle:
Pass
Fail
Unknown
555
666
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888
999
Left Ankle:
Pass
Fail
Unknown
555
666
777
888
999
555
666
777
888
999
=
=
=
=
=
Could not do due to physical problems
Could not do due to mental problems
Could not do due to both physical and mental problems
Refused, but theoretically could do
Did not do due to technical problems
4
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
b.
/ 2 0
Screening Examination
Paresthesia
aft
Say: "Do you have any feelings of tingling, pricking, or numbness in your legs,
ankles, or feet?"
Absent
4.
Present
Unknown
555
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Sensory Proprioception
(*Examiner's note: Continue with the participant in a supine position. This test is done on
one foot at a time with the participant in a seated position with their eyes closed. Grasp the
big toe on one of the participant's feet, and move it upwards while informing the participant
of the direction of motion. Then move the toe downwards while informing the participant of
the direction of motion. Then, to test, move the toe in either direction without providing a
verbal cue.)
Say: "I am going to hold your big toe and move it up and down. Then I will tell you what
direction I am moving your toe the first couple of times. Then I will ask you to tell me which
direction I am moving it. First, I will test your right foot, and then your left. Ready? Please
close your eyes."
Demonstrate and Say: "This is up. This is down."
(*Examiner's note: Complete demonstration. Then, begin test sequence. Conduct five tests
with each toe.)
Ask: "What direction am I bending your toe?"
Toe Test
Pass
Fail
Unknown
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Left Foot:
Pass
Fail
Unknown
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666
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999
dr
Right Foot:
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666
777
888
999
=
=
=
=
=
Could not do due to physical problems
Could not do due to mental problems
Could not do due to both physical and mental problems
Refused, but theoretically could do
Did not do due to technical problems
5
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
PARTICIPANT STANDING
Examiner Note: Participant must wear shoes
Neurological Tests
aft
E.
1.
Romberg Sign
Demonstrate and say: "Stand with your feet together, but not touching, and without touching
anything for support, like this. Now close your eyes."
(*Examiner's note: Be prepared to catch the participant if they are unstable.)
Romberg sign in 10 seconds:
Trial 1
Absent
Skip to Pronator Drift
Present
Skip to Trial 2
Unknown
666
555
777
888
999
888
999
Romberg sign in 10 seconds:
Trial 2
2.
Absent
Skip to Pronator Drift
Present
Go to General Appearance
Unknown
666
555
777
Pronator Drift
dr
Demonstrate and say: "Stand and hold your arms stretched out straight in front of you with
your palms up and eyes closed, like this, until I tell you to stop."
Pronator drift in 30 seconds:
Absent
F.
Present
Unknown
555
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999
General Appearance
Normal
Abnormal
Unknown
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Comments
6
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Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
Physical Performance Tests
aft
(*Examiner note: Participant must wear shoes)
G.
SINGLE CHAIR STAND
Describe: "This is a test of strength and stability in your legs in which you stand up from a chair
without using your arms."
Demonstrate and say: "Fold your arms across your chest, like this, and stand when I say GO,
keeping your arms in this position and sit back down again. Any questions?"
Test: "Ready, Go!"
Go to standing balance
Participant refused
(Includes no time/no tester)
Not attempted, unable
Attempted, unable to stand
Rises using arms
Stands without using arms
Go to standing balance
Go to standing balance
Go to repeated chair stands
REPEATED CHAIR STANDS
Describe: "This time I want you to stand up 5 times as quickly as you can keeping your arms folded
across your chest."
Demonstrate and say: "When you stand up, come to a full standing position each time, and when
you sit down, sit all the way down each time. I will demonstrate two chair stands to show you how it
is done."
(*Examiner note: Rise two times as quickly as you can, counting as you sit down each time.)
dr
H.
Go to standing balance
Test: "When I say GO stand five times in a row, as quickly as you can, without stopping. Stand up
all the way and sit all the way down each time.
Ready, Go!"
(*Examiner note: Start timing as soon as you say "GO." Count: "1, 2, 3, 4, 5" as the
participant sits down each time.)
Go to standing balance
Participant refused
(Includes no time/no tester)
Go to standing balance
Number completed
Not attempted, unable
Attempted, unable to complete 5 stands
0
1
2
3
4
Completes 5 stands
.
Enter time for 5 stands
7
Seconds
Hundredths
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
aft
INTRODUCTION: "I'm going to ask you to stand in several different positions that test your
balance. I'll demonstrate each position and then ask you to try to stand in each position for up to 10
seconds. I'll stand next to you to provide support if you lose your balance. Do you have any
questions?"
I.
SIDE-BY-SIDE STAND
Describe: "First I would like you to try to stand with your feet together, side-by-side, for 10
seconds."
Demonstrate and say: You can use your arms, bend your knees, or move your body to maintain
your balance, but try not to move your feet. Try to hold this position until I tell you to stop.
(*Examiner Note: Allow the participant to hold onto your arm to get balanced.)
Test: "Hold onto my arm while you get in position. When you are ready, let go."
(*Examiner Note: Start timing when the participant lets go or when they are in position.)
Go to 4 meter walks
Participant refused
(Includes no time/no tester)
Not attempted, unable
Unable to attain position or hold for one second
Holds for less than 10 seconds
Holds for 10 seconds
Go to 4 meter walks
Go to 4 meter walks
Go to semi-tandem stand
SEMI-TANDEM STAND
Describe: "Now I would like you to try to stand with the side of the heel of one foot touching the big
toe of the other foot for 10 seconds. Please watch while I demonstrate."
Demonstrate and say: "You may put either foot in front. You can use your arms and body to
maintain your balance. Try to hold your feet in position until I say stop. If you lose your balance,
take a step like this."
dr
J.
Go to 4 meter walks
(*Examiner Note: Allow the participant to hold onto your arm to get balanced.)
Test: "Hold onto my arm while you get in position. When you are ready, let go."
(*Examiner Note: Start timing when the participant lets go or when they are in position.)
Participant refused
Go to 4 meter walks
(Includes no time/no tester)
Not attempted, unable
Unable to attain position or hold for one second
.
Holds position less than 10 seconds
Seconds
Holds position for 10 seconds
8
Go to 4 meter walks
Go to 4 meter walks
Go to 4 meter walks
Hundredths
Go to tandem stand
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
STANDING BALANCE
TANDEM STAND
aft
K.
Describe: "Now I would like you to try to stand with the heel of one foot in front of and touching the
toes of the other foot for 10 seconds. Please watch while I demonstrate."
Demonstrate and say: "You may put either foot in front. You can use your arms and body to
maintain your balance. Try to hold your feet in position until I say stop. If you lose your balance,
take a step like this."
(*Examiner Note: Allow the participant to hold onto your arm to get balanced.)
Test: "Hold onto my arm while you get in position. When you are ready, let go."
(*Examiner Note: Start timing when the participant lets go or when they are in position.)
Trial 1
Go to 4 meter walks
Participant refused
(Includes no time/no tester)
Go to 4 meter walks
Go to 4 meter walks
Not attempted, unable
Unable to attain position or hold for one second
.
Holds position less than 10 seconds
Seconds
Hundredths
Go to 4 meter walks
Holds position for 10 seconds
Say: "Let's try this one more time."
Go to trial 2
Trial 2
Go to 4 meter walks
Not attempted, unable
Go to 4 meter walks
Unable to attain position or hold for one second
Go to 4 meter walks
dr
Participant refused
.
Holds position less than 10 seconds
Seconds
Holds position for 10 seconds
9
Go to 4 meter walks
Hundredths
Go to 4 meter walks
59451
Screening Protocol ID:
Date Completed:
Tester ID:
/
S C R IDEAL
/ 2 0
Screening Examination
4 METER WALKS
aft
INTRODUCTION: "I'm going to ask you to do a few short walks over this 4 meter course. First, I
want you to walk at your normal walking pace. For the second walk, I will ask you to walk as quickly
as possible. I will ask you to do each walk 2 times. Do you have any questions?"
MEASURED METERS:
Four meters
Three meters
No three meter space available
USUAL PACE
Describe: "Let's begin with the normal pace walk."
Demonstrate and say: "Place your feet with your toes behind, but just touching the starting line, like
this. Please walk at your normal pace."
(*Examiner note: Demonstrate and return.)
Say: "Walk a few steps past the finish line. Any questions?"
(*Examiner note: To start the test help the participant into position then drop your arm.)
Say: "Ready? Go."
Trial 1
End performance testing
Participant refused
(Includes no time/no tester)
End performance testing
Not attempted, unable to walk
Completes with walking aid
.
Seconds
Go to trial 2
Hundredths
dr
L.
Completes without walking aid
.
Seconds
Go to trial 2
Hundredths
Trial 2
Participant refused
End performance testing
Not attempted, unable to walk
End performance testing
Completes with walking aid
.
Seconds
Completes without walking aid
Hundredths
.
Seconds
10
Go to fast walk
Go to fast walk
Hundredths
59451
Screening Protocol ID:
Date Completed:
Tester ID:
/
S C R IDEAL
/ 2 0
Screening Examination
4 METER WALKS
FAST PACE
aft
M.
Describe: "Now let's do the fast pace walk."
Demonstrate and say: "Place your feet with your toes behind, but just touching the starting line.
When I say, "Go", please walk as fast as you can. Remember to walk a few steps past the finish line.
Any questions?"
(*Examiner note: To start the test help the participant into position then drop your arm.)
Say: "Ready? Go."
Trial 1
End performance testing
Participant refused
(Includes no time/no tester)
End performance testing
Not attempted, unable to walk
Completes with walking aid
.
Seconds
Completes without walking aid
Go to trial 2
Hundredths
.
Seconds
Go to trial 2
Hundredths
Trial 2
Participant refused
End performance testing
Not attempted, unable to walk
End performance testing
Completes with walking aid
.
Hundredths
dr
Seconds
End testing
Completes without walking aid
.
Seconds
11
End testing
Hundredths
59451
Screening Protocol ID:
Tester ID:
Date Completed:
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S C R IDEAL
/ 2 0
Screening Examination
COGNITIVE EXAM
aft
BLESSED MENTAL STATUS
INTRODUCTION: "Now I would like to give you a short memory test that will take about 5
minutes. Some questions will be easy and some will be more difficult. Are you ready?"
(*Examiner note: For rapid scoring, fill-in the correct answer for all items marked with an "*",
prior to test administration. Read all questions as written. If clarification is required, read the
alternate text (Alt:)).
*1. What is your name (correct name:
)?
Correct
Incorrect
Participant response
*2. Can you tell me your age (correct age:
)? (Alt: Please tell me your age.)
Correct
Incorrect
Participant response
*3. When were you born (correct month, year:
(year) were you born?)
)? (Alt: In what month
Correct
Incorrect
Participant response
4.
Where were you born (accept: city/town and state or country, if foreign born)?
(Alt: In what city (state) were you born?)
Correct
Incorrect
Participant response
5.
Where are you right now? (Alt: What is the name of this place, hospital,
study, unit?)
dr
N.
Correct
Incorrect
Correct
Incorrect
Participant response
6.
What is the name of the street that we are on?
Participant response
*7. How long have you lived here (correct number of years (+/- 1)
Correct
)?
Incorrect
Participant response
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/ 2 0
Screening Examination
BLESSED MENTAL STATUS
What city are we in (correct response: Baltimore)?
aft
8.
Correct
Incorrect
Participant response
9.
What state are we in?
(Examiner Note: Record answer in error. Enter 'X' if no response. Omit question
if interview is taking place in Washington, DC.)
Correct
Incorrect
Participant response
10. What county are we in?
(Examiner Note: Record answer in error. Enter 'X' if no response. Omit question
if interview is taking place in Baltimore City or Washington, DC.)
Correct
Incorrect
Participant response
*11. What is today's date (correct day of the month (e.g., 16th)
within a day):
)?
Correct
Incorrect
Participant response
dr
*12. What is the current month (correct month:
)?
Correct
Incorrect
Participant response
*13. What is the current year (correct year:
)?
Correct
Incorrect
Participant response
*14. What day of the week is today (correct day of the week:
Correct
)?
Incorrect
Participant response
*15. What part of the day is it (correct time of day (e.g., morning, afternoon, evening,
night):
)?
Correct
Incorrect
Participant response
13
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Screening Protocol ID:
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Date Completed:
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S C R IDEAL
/ 2 0
Screening Examination
BLESSED MENTAL STATUS
aft
*16. Without looking at a watch or clock, give me your best guess about what
time it is (correct time within one hour of start time:
).
Correct
Incorrect
Participant response
*17. What season is this (correct season‡(e.g., spring, summer, fall, winter)
within a day:
)?
Correct
Incorrect
Participant response
‡
not
e:
The
"
of
f
i
ci
al
"
dat
es
of
t
he
change
of
seasons
var
y
f
r
om
year
t
o
year
.
We
have
i
ndi
cat
ed
what
t
he
dat
es
of
t
he
change of seasons tend to be. Accept one day on either side of the actual change of the season. For example, if the
first day of winter is December 21st, a participant will get that item correct if s/he says either fall or winter on
December 20th, 21st or 22nd.
Spring: begins March 20 (accept either winter or spring from March 19 to March 21)
Summer: begins June 21 (accept either spring or summer from June 20 to June 22)
Fall: begins September 23 (accept either summer or fall from September 22 to September 24)
Winter: begins December 21 (accept either fall or winter from December 20 to December 22)
INTRODUCTION: "Now I'm going to tell you a name and address that I would like you to
remember for later. After I give you the name and address, I want you to repeat it right back
to me to make sure you heard it correctly. Ready? Here it is: (speak clearly and slowly) John
Brown, 42 Market Street, Chicago." If the participant does not voluntarily repeat the name
and address, say: "What did I just say?" If the participant cannot repeat the full name and
address, say "Let's try that again.
dr
"Repeat after me:
"John Brown. Your turn."
"Repeat after me:
"42 Market Street. Your turn."
"Chicago. Your turn." If the participant cannot repeat each component correctly, provide the
name and address again, one word at a time. Record outcome below.
18. When did the participant correctly repeat John Brown, 42 Market Street, Chicago?
First time
When given in 3 phrases
When given in single words
Could not repeat
14
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Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
BLESSED MENTAL STATUS
aft
19. What is your mother's first name (accept: anything resembling a first name)?
Correct
Incorrect
Participant response
20. How much schooling did you have (accept: number of years or number or type
of degrees)?
Correct
Incorrect
Participant response
21. What is the name of one specific school that you attended (accept: anything
reasonable)?
Correct
Incorrect
Participant response
22. What kind of work have you done (accept: anything reasonable)?
Correct
Incorrect
Participant response
23. Can you tell me who the president of the United States is right now (correct
president:
)?
Correct
Incorrect
Participant response
24. Who was the president before (Mr. Obama) (correct previous
)?
dr
president:
Correct
Incorrect
Participant response
25. Can you tell me one of the years of World War I (accept: any year from 1914
to 1918)?
Correct
Incorrect
Participant response
26. Can you tell me one of the years of World War II (accept: any year from 1938
to 1945)?
Correct
Incorrect
Participant response
15
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S C R IDEAL
/ 2 0
Screening Examination
BLESSED MENTAL STATUS
aft
(*Examiner note: For questions N27 to N29, indicate errors by putting a line through the
month/number and self-corrections by darkening the box above the month/number. If
participant self-corrects two or more times, then score as incorrect.)
27. Now, I would like you to recite the months of the year backwards (in
reverse order), starting with December. Start with December, begin ...
DEC
NOV
OCT
SEP
AUG
JUL
JUN
Correct
MAY
APR
MAR
Self-corrected error
FEB
JAN
Incorrect
28. Now, I would like you to count from 1 to 20.
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20
Correct
Self-corrected error
Incorrect
29. Now, I would like you to count backwards from 20 to 1.
20 19 18 17 16 15 14 13 12 11 10
Correct
9
8
7
6
5
4
Self-corrected error
3
2
1
Incorrect
dr
30. Now, can you recall that name and address you learned a little while ago?
(*Examiner Note: If the participant
cannot recall the name and address
spontaneously, cue with "John Brown,"
one time only and score John and
Brown as incorrect. No additional
prompts are allowed. Score the other 3
units (42, Market Street, Chicago)
based on participant response.)
John
Correct
Incorrect/Omitted
Brown
Correct
Incorrect/Omitted
42
Correct
Incorrect/Omitted
Market Street
Correct
Incorrect/Omitted
Chicago
Correct
Incorrect/Omitted
16
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S C R IDEAL
/ 2 0
Screening Examination
aft
(*Examiner Note: Compute a prelimnary total score as the number of errors or incorrect
responses. For questions N1 through N26 and question N30, count up the number of darkened
boxes to the far right. For questions N27 to N29, add one point for a self-corrected error and 2
points for incorrect.)
*
Validated total:
Preliminary error total:
*
If
not
done
f
or
t
echni
cal
reasons
(no
t
i
me,
no
t
est
er
),
pl
ease
assi
gn
"99";
i
f
r
ef
used,
"88".
MINI MENTAL EXAM
31. "I am going to say three words for you to remember. Repeat them after I
have said all three words: shirt, blue, honesty."
(*Examiner Note: Do not repeat the words for the participant until after the first
trial. The participant may give the words in any order. If there are errors on the first
trial, repeat the items up to six times until they are learned."
Shirt
Correct
Error/Refused
Not attempted/disabled
b.
Blue
Correct
Error/Refused
Not attempted/disabled
c.
Honesty
Correct
Error/Refused
Not attempted/disabled
d.
Number of presentations necessary for the participant to repeat
the sequence:
dr
a.
32. "Spell 'world'"
Able to spell
Unable to spell
If unable to spell: "It's spelled W-O-R-L-D."
"Now spell 'world' backwards."
(*Examiner Note: Record letters in order given. Enter "xxxxx" if no response.)
17
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
33. "What three words did I ask you to remember earlier?"
Shirt
aft
a.
Spontaneous recall
Correct word/incorrect form
After "Something to wear."
After "Was it shirt, shoes, or socks?"
Unable to recall/refused (provide the correct answer)
Not attempted/disabled
b.
Blue
Spontaneous recall
Correct word/incorrect form
After "Something to wear."
After "Was it shirt, shoes, or socks?"
Unable to recall/refused
(provide the correct answer)
Not attempted/disabled
c.
Honesty
Spontaneous recall
Correct word/incorrect form
After "Something to wear."
dr
After "Was it shirt, shoes, or socks?"
Unable to recall/refused
(provide the correct answer)
Not attempted/disabled
34. (*Examiner Note: Point to the object and ask the participant to name it. Score
"Error/Refused" if the participant cannot name it within 2 seconds or gives an
incorrect name. Do not wait for the participant to mentally search for the name.)
a.
Pencil: "What is this?"
Correct
b.
Error/Refused
Not attempted/disabled
Wristwatch: "What is this?"
Correct
Error/Refused
Not attempted/disabled
18
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
35. "Now repeat: No ifs, ands, or buts"
aft
(Examiner Note: Pronounce the individual words distinctly but with normal tempo of
a spoken sentence. Give no credit if the participant misses the "s.")
a.
No ifs:
Correct
Error/Refused
Not attempted/disabled
b.
ands:
Correct
Error/Refused
Not attempted/disabled
c.
or buts:
Correct
Error/Refused
Not attempted/disabled
36. (*Examiner Note: Hold up Card B and say, "Please do this."
If the participant does not close their eyes within 5 seconds, prompt by pointing to
the sentence and saying, "Read and do what this says."
If the participant has already read the sentence aloud spontaneously, simply say,
"Do what this says."
Allow 5 seconds for the response. Assign the appropriate score (see below). As soon
as the participant closes their eyes, say, "Open."
Closes their eyes without prompting
Closes their eyes after prompting
Reads aloud, but does not close eyes
Does not read aloud or close eyes/refused
Not attempted/disabled
37. "Please write the following sentence: I would like to go out."
dr
(*Examiner Note: Hand participant a piece of blank paper and a #2 pencil with
eraser. If necessary, repeat the sentence word by word as the participant writes.
Allow a maximum of 1 minute after the first reading of the sentence for scoring the
task.
Either printing or cursive is allowed. Score "Correct" for each correct word, but no
credit for "I." For each word, score "Error/Refused" if there are spelling errors or
incorrect mixed capitalizations (all letter printed in uppercase are permissible).
Self-corrected errors are acceptable.)
a.
Would:
Correct
Error/Refused
Not attempted/disabled
b.
Like:
Correct
Error/Refused
Not attempted/disabled
c.
To:
Correct
Error/Refused
Not attempted/disabled
d.
Go:
Correct
Error/Refused
Not attempted/disabled
e.
Out:
Correct
Error/Refused
Not attempted/disabled
19
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
/ 2 0
Screening Examination
38. "Here is a drawing. Please copy the drawing onto this piece of paper."
aft
(*Examiner Note: Hand participant Card C. Allow 1 minute for copying. For
r
i
ght
handed
par
t
i
ci
pant
s,
pr
esent
t
he
sampl
e
on
t
he
l
ef
t
si
de;
f
or
t
he
l
ef
t
handed
participants, present the sample on the right side. Allow a maximum of 1 minute for
response. Do not penalize for self-corrected errors, tremors, minor gaps, or
overshoots.)
a.
Pentagon 1
5 approximately equal sized
5 sides, but longest:shortest side is >2:1
Nonpentagon enclosed figure
2 or more lines, but it is not an enclosed figure
Less than 2 lines/refused
Not attempted/disabled
b.
Pentagon 2
5 approximately equal sized
5 sides, but longest:shortest side is >2:1
Nonpentagon enclosed figure
2 or more lines, but it is not an enclosed figure
Less than 2 lines/refused
Not attempted/disabled
Intersection
dr
c.
4-cornered enclosure
Not a 4-cornered enclosure
No enclosure/refused
Not attempted/disabled
39. (*Examiner Note: Refer to Question N38 to check whether the participant is right- or
left-handed. Ask them to take the paper in their non-dominant hand.)
"Take this paper with your left (right for left-handed person) hand, fold it in half
using both hands, and hand it back to me."
(*Examiner Note: After saying the whole command, hold the paper within reach of
the participant. Do no repeat any part of the command. Do not move the paper
toward the participant. The participant may hand back the paper with either hand.)
20
59451
Screening Protocol ID:
Tester ID:
/
S C R IDEAL
a.
Date Completed:
/ 2 0
Screening Examination
Takes paper in correct hand
Error/Refused
Not attempted/disabled
aft
Correct
b.
Folds paper in half
Correct
Not attempted/disabled
Hands paper back
Correct
Error/Refused
Not attempted/disabled
dr
c.
Error/Refused
21
59451
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R IDEAL
O.
/ 2 0
Screening Examination
Electrocardiogram
Yes
No
Physical
Refused
Cognitive
Technical problems
aft
Was EKG done?
Physical and cognitive
Other
Comments:
Blood Draw
Lab testing:
(1) 3ml lavender top
(1) 3.5ml SST top
Fasting except water since:
Bloow draw: # attempts
(see order sheet for distribution)
am
pm
:
Location:
10 hour fast?
Yes
2 - Left
3 - Both
Comment?
2 - Upper arm
3 - Lower arm
4 - Hand
time drawn
22
No
1 - Antecubital
1 - Right
dr
P.
:
59451
| File Type | application/pdf |
| Author | legum_g |
| File Modified | 2010-11-18 |
| File Created | 2010-09-22 |