Name ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟
Sex ͟ ͟ ͟ ͟ ͟
Age ͟ ͟ ͟
Education ͟ ͟ ͟ Date of exam ͟ ͟ ͟ ͟ ͟
Administered by ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟ ͟
MONTREAL COGNITIVE ASSESSMENT (MOCA-B)
BASIC
EXECUTIVE FUNCTION
SCORE
START
TIME
(
ROSE
IMMEDIATE RECALL
HAND
BLUE
13.………….
N
2.…………….
8.…………….
3.…………….
9.…………….
4.…………....
10.…………....
5.……………
11.……………
6.……………
12.……………
14.…………….
15.…………….
16.…………....
17.……………
18.……………
ORIENTATION
[ ] time (± 2 hr)
[ ] day
] 1……………………………
[
] 2. …………………………
[
To wha t ca tegory these objects belong to ?
ABSTRACTION
[
DELAYED RECALL
Poi nts a re awarded for
reca l l wi th No cue
(1point for each item)
]
train - boat
Recall with
No cue
Recall with
category cue
Recall with
multiple choice cue
VISUOPERCEPTION
Identify drawings. No more than 60
s econds. See complementary s heet.
ATTENTION
[ ] year
[
[ ] place
[ ] city
] north - south
Adapted by : Parunyou Julayanont MD
Copyright : Z. Nasreddine MD
] drum - flute
CHAIR
HAND
BLUE
SPOON
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
T-shirt
banana
lamp
candle
watch
cup
leaf
key
spoon
3 points
2 points
1 point
0 point
[ ] peacock
[ ] tiger
if N = 9-10
if N = 6-8
if N = 4-5
if N = 0-3 N
ERROR ͟ ͟ N
8 5 1 3 0 2 9 2 0 4 9 7 8 6 1 5 76 4
1 5 8 3 9 20 3 9 4 0 2 1 6 8 7 4 6 7 5
ERROR ͟ ͟ N
No point if 2 errors or more
2 points if 2 errors or less
1 point if 3 errors
0 point if 4 errors or more
TOTAL SCORE (
Final Version June 04, 2014
(
/6)
(
/3)
(
/3)
(
/5)
(
/3)
(
/4)
(
/1)
(
/2)
͟
[ ] butterfly
15 8 392 03 9 4 0216 874675
Name the numbers in circles & squares : 3
See complementary s heet.
[
ROSE
scissors
Na me the numbers i n circles.
See complementary s heet.
/2)
] 3. …………………………
( e.g. ora nge - banana = frui t )
Identify a nimals. See complementary s heet. [ ] zebra
(
2 points if N = 13 or more
1 point if N = 8-12
0 point if N = 7 or less
(3 points if 3 ways, 2 points if 2 ways, 1 point if 1 way, 0 point if no correct way)
“13 Dollars”
NAMING
[ ] month
items
Provi de 3 ways to pay using 1 dollar coins, 5 dollar and 10 dollar bills for a n object that costs exactly
CALCULATION
[
No point
2nd trial
Na me maximum numbers of FRUITS in 1 mi nute
1.………….
7.………….
SPOON
1st trial
Perform 2 tri a ls even i f
1st tri a l is s uccessful
FLUENCY
CHAIR
/1)
END TIME
/30)
Add 1 point if education < 4 year AND add 1 point if illiterate
TOTAL TIME
͟ ͟ ͟ ͟ ͟ min ͟ ͟ ͟ ͟ ͟ sec
MONTREAL COGNITIVE ASSESSMENT (MOCA-B)
BASIC
COMPLEMENTARY WORKSHEET
VISUOPERCEPTION
NAMING
ATTENTION
Adapted by: Parunyou Julayanont MD
Copyright:
Z. Nasreddine MD
Final Version June 04, 2014