Name:
DOB:
Sex:
Education:
COLORADOCOGNITIVEASSESSMENT(CoCA)
Age:
Date:
1.ProspectiveMemoryTest:Supposetheexamineehastolookatabankstatement.Whenthetestis
over,instructexamineethatheorshehastolookatabankstatement.
Point
s
2.ShapeTrailTest(RefertoSupplement1):Alternatebetweensquareandcircleinascendingorderof
numbers.Discontinueafter2mins(Zhaoetal.,2013). ___________(sec)÷________(correctlines)=
3.VerbalListLearning:Readlistofwords.Administer3trials.Examineecanrepeatwordsinanyorder.
Pleaserecordexaminee’sanswersverbatim.Score=1ptforeachaccuratelyrecalledwordineachtrial.
Car
River
Market
Desk
Foot
Square
Teacher
(Other)
Trial1
Trial2
Trial3
/21
4.FigureCopy(RefertoSupplement2):CopyMigure.Discontinueafter2minutes.Score=1pteachfor
AccuracyandPlacement(seebelow)
Accuracy
Placement
/18
5.AnimalFluency(RefertoSupplement
3):Discontinueafter1minute.Score=1ptfor
eachcorrectword
OuterRectangle
InnerPlus
6.LexicalFluency“S”(Referto
Supplement3):Discontinueafter1minute.
Score=1ptforeachcorrectword
InnerDiagonals
Concentric
Rectangles
7.WorkingMemory:Examineesays
numbersinreverseorderofpresentation.
Score:0.5ptforcorrectdigit,0.5for
correctplacementofdigit
Sample:
Hoops
InnerTriangle
InnerVertical
Lines
5
InnerCircles
Q
0
L
3
Digit
Ramparts
Order
Total
Trial1:
2
F
7
C
S
9
N
Digit
Order
Trial2:
/3
3
T
S
7
V
0
B
K
1
Y
6
U
Digit
Order
Assessor
/5
CoCATotalPage1:
COLORADOCOGNITIVEASSESSMENT(CoCA)
Name:
DOB:
Sex:
Education:
Age:
Date:
8.FocusedAttention:Whenyousayeyes,examineesayssee.Whenyousaynose,examineesayssmell.
Placeacheckmarkoverallcorrectresponsesincludingthelackofaresponsewhenappropriate
Score:1ptforallcorrectresponses.
Point
s
Eyes;aisle;note;iron;nose;small;eyes;seat;note;nose;hose;nod;aisle;eyes;seat;nod;nose;eyes;
aisle;nose;small;eyes;nod;iron;note;eyes;seat;lies;nose;aisle;iron;note;lies;nose;small;hose;
/42
eyes;nose;aisle;lies;hose;note
9.ClockCommand(RefertoSupplement4):Drawclockwithallthenumbers.Showtimeat10past11.
Refertoscoringinmanual.Scoreisoutof10points.
10.ClockCopy(RefertoSupplement5):Copyclock.Samescoringcriteriaasitem9above.
/10
/10
11.Similarities:Statehowtwothingsaresimilar.Score:0=nosimilarity,1=concreteresponse,2=
abstractresponse
Sample:Howareapotatoandanonionalike(vegetables)
a.  Howaretelevisionandradioalike(modesofinformation/entertainment)
/2
b.  Howaretallandshortalike?(waysofdescribingheight)
/2
12.NumberSymbolMatchingTest(RefertoSupplement6AforwrittenandSupplement6Bfor
oralversion):Discontinueeachafter30sec.Scoreonlywrittenversion=1ptforallcorrectresponses.
/63
13.VerbalNaming:Examineehastoidentifywhatyouaredescribing.Placeacheckmarkifcuewasgiven.Score
=1ptforallcorrectresponseswithoutcue.(AdaptedfromYochimetal.,2015).
Item
Answer
1.Whaticedoeswhenitgetshot
Melt
2.Whatyouusetomeasurehowmanyinchessomethingis
Ruler
3.Along,severesnowstorm
Blizzard
4.Whatyouputyourheadontosleepatnight
Pillow
5.Thepartoftheshirtthatcoversyourarms
Sleeves
6.ApersonwhoworksatadrugstoretoYillprescriptions
Pharmacist
7.Amovingsetofstairs
Escalator
8.Adevicethatmeasurestemperature
Thermometer
9.Whatdoyoudotoapencilorknifethatbecomesdull
Sharpen
10.Aplacepeoplegotogamblemoney
Casino
11.Whenyoutakeadeepbreathwhenyoursleepyorbored
Yawn
12.Ababycow
Calf
13.Adesertplantthathasspikes
Cactus
14.AtoythathasastringandYloatsintheairwhenitiswindy
Kite
15.Thepoisonasnakeusestokillitsprey
Venom
Cue
Score
/15
CoCATotalPage2:
COLORADOCOGNITIVEASSESSMENT(CoCA)
Name:
DOB:
Sex:
Education:
Age:
Date:
14.Orientation:Score=1ptforeachcorrectresponse
Date MonthYearDayPlaceCityStatePresident
Points
/8
15.VerbalListLearningDelayedRecall:Askexamineetostateallwordsrememberedfromthelist.
Providecategorycueforallwordsnotrecalled.Score:1ptforeachcorrectresponse
Car
River
Market
Desk
Foot
Square
Teacher
(autom
obile)
(water
body)
(where
youbuy
somethi
ng)
(furnitur
e)
(partof
the
body)
(geomet
ric
Yigure)
(professi
on)
(Other)
Free
Category
/14
16.VerbalListLearningYes/NoRecognition:Readeachwordlistedbelowandaskexamineeto
answerineitheryesorno.Score=1ptforeachcorrectanswer.
1.FootY/N2.TableY/N3.RiverY/N4.StoreY/N5.SquareY/N
6.DeskY/N7.HandY/N8.CarY/N9.MarketY/N10.ArtistY/N
11.RectangleY/N12.StreamY/N13.BusY/N14.TeacherY/N
/14
17.VerbalListLearningForcedChoiceRecognition:Askexamineetopickcorrectword.
1.SevenorCar2.FightorTeacher3.TelevisionorFoot4.MarketorVoice
5.DeskorCountry6.GameorSquare7.RiverorEducation
/7
18.FigureDelayedRecall(RefertoSupplement7):AskexamineetodrawMigurefrommemory.Score
=1pteachforAccuracyandPlacement(seebelow)
/18
Accuracy
Placement
19.ProspectiveMemoryTestDelayed
Recall:Telltheexamineethattestisover.
Score=1ptifexamineeremindsyouthathe
orshehastolookatabankstatement
20.TestofFunctionalAbilities:Show
examineeSupplement8.
20A.Doyouhaveenoughmoneyinyour
accounttomakeyourutilitiespaymentof
$189.75?
YesNo
IfNo,continuetoitemB.IfYes,tellthemthat
theanswerisNo.Thenask,itemBbelow.
OuterRectangle
InnerPlus
InnerDiagonals
Concentric
Rectangles
Hoops
InnerTriangle
InnerVertical
Lines
20B.Whatwillhappenifyoumakethis
paymentfromyouraccountanyway?(Score
=1ptforeachofthefollowing:stillhaveto
paybill,overdrawnaccount,andfeecharged)
___________________________________________________
InnerCircles
Ramparts
Total
Page1:
+
Page2:
+
Page3:
=
CoCATotal:
CoCATotalPage3:
/1
/1
/3
Supplement1
ShapeTrailTest
Name:
Date:
Supplement2
FigureCopy
Name:
Date:
Supplement3
AnimalandLexicalFluency
15secs
30secs
45secs
1min
Animals
Name:
Date:
“S”Words
Supplement4
ClockCommand
Name:
Date:
Supplement5
ClockCopy
Name:
Date:
11
12
1
2
10
3
9
8
4
7
6
5
)
b
S
z
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)
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a
a b z
! f S
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2
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z
S
S
f
4
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z
7
S !
b Z
b !
b
6
Name:
Date:
a f !
a
a
5
f b Z
Z
Z
a
|
3
Supplement6A
NumberSymbolMatchingTest-Written
z
S
z
b
)
z !
Z
Z
8
)
S
)
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f b
S
|
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9
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)
a
a b z
! f S
z !
S
2
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1
Supplement6A
NumberSymbolMatchingTest-Oral
z
S
S
f
4
|
z
b
|
)
z
7
S !
b Z
b !
b
6
a f !
a
a
5
f b Z
Z
Z
a
|
3
Name:
Date:
z
S
z
b
)
z !
Z
Z
8
)
S
)
z
f b
S
|
!
9
|
Z
! a
|
a f
a
Supplement7
FigureDelayedRecall
Name:
Date:
Supplement8
TestofFunctionalAbilities
Name:
Date:
XYZBankCombinedStatementofAccounts
Primaryaccountnumber:8887779999
May18,2016-June17,2016
Page1of3
HappySmile
123HappyLaneApt555
SampleCityZZ88888-7777
XYZBank
YouandXYZBank
ThankyouforbeingaloyalXYZBankcustomer.Wevalueyourtrustinourcompanyandlook
forwardtoconYnuingtoserveyouwithyourfinancialneeds.
Ques/ons?
Availablebyphone24hoursaday,7
daysaweek:
TelecommunicaYonsRelayServices
callsaccepted
1-800-TO-ABCDE(1-800-869-11122)
Online:xyzbank.com
IMPORTANTACCOUNTINFORMATION
Whencanyouraccountbeclosed?
WecancloseyouraccountatanyYme.Iftheaccountisclosed,wemaysendtheremainingbalanceondepositinyouraccountbytradiYonal
mailorcreditittoanotheraccountyoumaintainwithus.
SummaryofAccounts
Checking/Prepaid
AccountPageAccountnumberEndingbalancelaststatementEndingbalancethisstatement
XYZChecking
18887779999
$1442.41
$172.06
Ac/vitySummary
Beginningbalanceon05/18$1,442.41
Deposits/AddiYons$500.00
Withdrawals/SubtracYons-1,770.35
Endingbalanceon06/16$172.06
Transac/onHistory
Date
Descrip/on
Deposits/Addi/ons
Withdrawals/Subtrac/ons
EndingBalance
05/19
McDonald’s#F21389Parker
$8.41
$1434.00
05/25
Deposit15859375
05/28
123Apartments,ColoradoSprings,CO
$1000.00
$934.00
06/02
KingSoopers,ColoradoSprings,CO
$52.70
$881.30
06/03
UnitedAirlines
$487.65
$393.65
06/05
ColoradoSpringsUYliYes
$98.37
$295.28
06/09
Applebees,ColoradoSprings,CO
$36.89
$258.39
06/10
LowesHardware,ColoradoSprings,CO
$76.14
$182.25
06/13
Starbucks,ColoradoSprings,CO
$10.19
$172.06
$500
$1934.00
Name:
Date:
Supplement9
ProcessScoringSheet
4.FigureCopy&18.FigureRecall
2.ShapeTrailsTest
ProcessVariables
ProcessVariables
Copy
Recall
Perseverations
SequencingError
SpatialError
SetLossError
PoorlyPlanned
CaptureError
RighttoLeftOrganization
VisuospatialNeglect
Neglect
VisualDifYiculties
Micrographia/Motor
Issues/Tremors
MotorDifYiculties/Tremors
Accuracy/PlacementRatio
Losingtrackandstarting
fromwrongtarget
Percentretained
5.AnimalFluency&6.LexicalFluency
3,15,&16.VerbalListLearningTest
ProcessVariablesFo
SemanticIntrusions
IR
DR
Y/
N
Process
Variables
Epoch1
Epoch2
Epoch3
PhonemicIntrusions
NovelIntrusions
Epoch4
Perseverations
Intrusions
Repetitions
PercentPrimacy
Recall
SelfCorrection
Percentsetloss
%perseveration
PercentRecency
Recall
SemanticIndex
RuleViolations
Animals
SWords
Supplement9
ProcessScoringSheet
7.TestofWorkingMemory
Name:
Date:
8.TestofFocusedAttention
ProcessVariables
ProcessVariables
Omissions
Omissions
Additions/
Commissions
Additions/Commissions
PerseverativeErrors
PerseverativeErrors
SetLossErrors
SetLossErrors
SequencingErrors
ProcessVariables
SizeofClock
GraphicalErrors
StimulusBoundErrors
ConceptualErrors
Spatial/PlanningDeYicits
Perseveration
Neglect
RotatedPaper
Self-correction
RequestedReminderofTime
CommandtoCopyRatio
9.ClockCommand
10.ClockCopy
ClockCommand
ClockCopy
Supplement9
ProcessScoringSheet
11.Similarities
ProcessVariables
In-SetErrors
Name:
Date:
12.NumberSymbolMatchingTest
Process
Variables
Process
Variables
NumberofErrors
#ofphonemic
cuesgiven
StimulusPull
Errors
#correctwith
phonemiccues
Perseverationof
Symbols
Phonemic
Paraphasia
Overwriting/
Micrographia/
Tremors
Semantic
Paraphasia
VagueResponse
Subordinate
Response
Out-of-SetErrors
Oneobject
Response
Juxtaposition
Response
DifferentResponses
13.VerbalNaming
Circumlocution
Expansionof
Symbols
Perseveration
BehavioralObservationsChecklist:Pleaseindicatethepresenceandratetheseverityofanyofthe
belowmentionedbehavioralfeatures:
1.Distractibility
None
Mild
Moderate
Severe
2.Impulsivity
None
Mild
Moderate
Severe
3.Reduced/LackofAffectand
SocialEngagement
None
Mild
Moderate
Severe
4.SociallyInappropriate
None
Mild
Moderate
Severe
5.DecreasedInitiation
None
Mild
Moderate
Severe
6.Agitation/Aggression/
Irritation
None
Mild
Moderate
Severe
7.Other:
None
Mild
Moderate
Severe