76 (76)    MH REPORT (601.93)

Name Value
REPORT NUMBER 76
INSTRUMENT STMS
RPT
.| .|  Short Test of Mental Status| |  Date Given: <.Date_Given.>|  Clinician: <.Staff_Ordered_By.>|  Location: <.Location.>| |  Veteran: <.Patient_Name_Last_First.>|  SSN: <.Patient_SSN.>|  DOB: 
complete and correct.|     <*Answer_5590*>| |  8. Information|   8A. Who is the current president of the United States?|     <*Answer_5591*>|   8B. Who was the first president of the United States?|  
   <*Answer_5592*>|   8C. Define an ISLAND.|     <*Answer_5593*>|   8D. How many weeks are there in a year?|     <*Answer_5594*>| |  9. Recall|   9A. Recall APPLE|     <*Answer_5595*>|   9B. Recall 
MR. JOHNSON|     <*Answer_5596*>|   9C. Recall CHARITY|     <*Answer_5597*>|   9D. Recall TUNNEL|     <*Answer_5598*>| | Copyright (c) 1987, Mayo Clinic Foundation. | | Information contained in this 
note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.  Assessment results should be verified for accuracy and used in conjunction with other diagnostic 
activities and procedures.|    $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|  Gender: <.Patient_Gender.>| | |     STMS Score: <-STMS Score->| |  Questions and Answers| |  1. Orientation|   1A. What is your name?|     <*Answer_5569*>|   1B. What 
is your address?|     <*Answer_5570*>|   1C. What building are we in now?|     <*Answer_5571*>|   1D. In what city are we now located?|     <*Answer_5572*>|   1E. What state are we in now?|     
<*Answer_5573*>|   1F. What is today's date?|     <*Answer_5574*>|   1G. What month is it?|     <*Answer_5575*>|   1H. What year is it?|     <*Answer_5576*>| |  2. Attention|   2A. Digit Span: 
2-9-6-8-3|     <*Answer_5577*>|   2B. Digit Span: 5-7-1-9-4-6|     <*Answer_5578*>|   2C. Digit Span: 2-1-5-9-3-6-2|     <*Answer_5579*>| |  3. Immediate Recall|   3A. How many trials were needed to 
learn all, some or none of the four words?|     <*Answer_5580*>|   3B. How many words were learned?|     <*Answer_5599*>| |  4. Calculation|   4A. What is 5 times 13?|     <*Answer_5581*>|   4B. What 
is 65 minus 7?|     <*Answer_5582*>|   4C. What is 58 divided by 2?|     <*Answer_5583*>|   4D. What is 29 plus 11?|     <*Answer_5584*>| |  5. Abstraction|   5A. How are ORANGE and BANANA alike?|    
 <*Answer_5585*>|   5B. How are DOG and HORSE alike?|     <*Answer_5586*>|   5C. How are TABLE and BOOKCASE alike?|     <*Answer_5587*>| |  6. Construction|   6A. Clock face is circular, and numbers 
are correctly placed.|     <*Answer_5588*>|   6B. The time is correctly drawn.|     <*Answer_5589*>| |  7.Copy the line drawing of a three dimensional cube (Necker's cube). The subject's drawing is