12 (12)    MH REPORT (601.93)

.|.|The Saint Louis University Mental Status Examination||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: 
results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.||Copyright (c) 2003 Saint Louis University|    $~
<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||SLUMS Score: <-Total Score->||High school education                  |     27-30 Normal|     21-26 Mild 
Neurocognitive Disorder|     1-20  Dementia ||Less than High School|     25-30 Normal|     20-24 Mild Neurocognitive Disorder|     1-19  Dementia|||Questions and Answers||A. Is the patient alert?|    
<*Answer_4940*>|B. Level of education:|    <*Answer_4951*>|1. What day of the week is it?|    <*Answer_5083*>|2. What is the year?|    <*Answer_5092*>|3. What state are we in?|    <*Answer_5093*>|4. 
Please remember these five objects. I will ask you what they are later. Apple Pen Tie House Car|    <*Answer_5338*>|5A. How much did you spend?|    <*Answer_5094*>|5B. How much do you have left?|    
<*Answer_5095*>|6. Please name as many animals as you can in one minute.|    <*Answer_5096*>|7. What were the five objects I asked you to remember?|    <*Answer_5097*>|8A. 87|    <*Answer_5098*>|8B. 
649|    <*Answer_5099*>|8C. 8537|    <*Answer_5100*>|9A. Hour markers:|    <*Answer_5101*>|9B. Time:|    <*Answer_5102*>|10A. Please place an X in the triangle.|    <*Answer_5103*>|10B. Which figure 
is the largest?|    <*Answer_5104*>|11A. What was the female's name?|    <*Answer_5105*>|11B. What work did she do?|    <*Answer_5106*>|11C. When did she go back to work?|    <*Answer_5107*>|11D. 
What state did she live in?|    <*Answer_5108*>|||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.  Assessment