Six-Item Cognitive Screener
“I would like to ask you some questions that ask you to use your memory. I am going to
name three objects. Please wait until I say all three words, then repeat them.
Remember what they are because I am going to ask you to name them again in a few
minutes. Please repeat these words for me: APPLE—TABLE—PENNY.” (Interviewer
may repeat names 3 times if necessary but repetition not scored.)
Did patient correctly repeat all three words?
1. What year is this?
2. What month is this?
3. What is the day of the week?
What were the three objects I asked you to remember?
4. Apple =
5. Table =
6. Penny =
Yes
No
Correct
0
0
0
Incorrect
1
1
1
0
0
0
1
1
1
TOTAL
Internal Use
Care Partners: To be eligible for this project, a patient must score less than 3
In general: A score of 2 or 3 indicates a need for further screening and diagnostic testing
Callahan, C.M., et al. Six-Item Screener to Identify Cognitive Impairment Among Potential Subjects for Clinical
Research. MEDICAL CARE Volume 40, Number 9, pp 771–781 ©2002 Lippincott Williams & Wilkins, Inc.