2013 COGNISTAT ACTIVE FORM

Name: _______________________________ Gender: _______ Date of birth: ____________ Educ: ______

City: _________________________ Age: ______ Lang: ______________ Handedness: (click)

Current occupation:_________________ Nature of last job: ___________ Date last worked:___________

Reason for hospitalization or visit to clinic: __________________________ Date of injury: ___________

Date of testing: __________ Time: ______ Inpatient: Outpatient: Location: ___________________

Past Medical History 1._________________________________________________

2._________________________________________________

3._________________________________________________

4._________________________________________________

Past Psychiatric History 1._________________________________________________

2._________________________________________________

3._________________________________________________

4._________________________________________________

Factors Potentially Influencing Test Performance (Check Y or N for each item) Comments CNS-Active Medications, Dosage

and Frequency, Check if None Neurological Condition ____________________ ________________________

Visual Impairment ____________________ ________________________

Hearing Loss / Tinnitus ____________________ ________________________

Dizziness / Vertigo ____________________ ________________________

Pain ____________________ ________________________

Substance Abuse ____________________ ________________________

Sleep Deprivation / Insomnia ____________________ ________________________

Poor Cooperation ____________________ ________________________

Psychiatric Disorder ____________________ ________________________

Fatigue ____________________ ________________________

English as a 2nd Language ____________________ ________________________

Learning Disorder ____________________ ________________________

ADHD ____________________ ________________________

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Litigation ____________________ ________________________

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I. LEVEL OF CONSCIOUSNESS:

Alert Lethargic Fluctuating

II. ORIENTATION Other ResponseA. Person

1. What is your full name?

2. What is your present age?

B. Place

1. Where are you right now?

2. What city are we in?

C. Time

1. What is the year?

2. What month is it?

3. What day of the week is it?

4. What is the date?

5. What time is it?

Total Score _________

A. Digit Repetition

Other Response Screen: 8-3-5-2-9-1 Pass Fail ________________________

III. ATTENTION

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B. Four Word Registration (Part 1) Give the four words (from group A, B or C) until the patient is able to repeat all four words on two sucessive trials. Click if correct and record incorrect answers. The Clock starts automatically when registration is complete.

1st 2nd 3rd 4th 5th 6th 7th 8th Incorrect Answers

Robin Carrot Piano Green

IV. LANGUAGE

A.

A. Speech Sample: Fishing Picture Record patient’s response verbatim.

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________

B. Comprehension Place a pen, some keys, a coin, an index card and three other objects (e.g. paper clip, rubber band, etc.) in front of the patient.

Screen: 3-step command: “Turn over the paper, hand me the pen, and point to your nose.”

Pass Fail

Metric

Other Response

a. Pick up the pen. __________________________________

b. Point to the floor. __________________________________

c. Hand me the keys. __________________________________

d. Point to the pen and pick up the keys. __________________________________

e. Hand me the paper and point to the coin. __________________________________

f. Point to the keys, hand me the pen, and __________________________________ pick up the coin.

Total Score _______

IV. LANGUAGE

Option Click to display optional 7, 8 and 9 digit sequences, which can be used for additional qualitative information only.

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C. Repetition

Screen: The beginning movement revealed the composer’s intention.

____________________________________________________________________________________

Pass Fail

Metric: Patient may make two attempts to repeat the statement.

Other Response

a. Out the window. ___________________________

b. He swam across the lake. ___________________________

c. The winding road led to the village. ___________________________

d. He left the latch open. ___________________________

e. The honeycomb drew a swarm of bees. ___________________________

f. No ifs, ands or buts ___________________________

Total Score __________

D. Naming Screen

a) Pen b) Cap or Top c) Clip d) Point, Tip, or Nib Pass Fail

Metric: (If incorrect, record response)

Other Response Other Response

a. Shoe __________________ e. Horseshoe __________________

b. Bus __________________ f. Anchor _ __________________

c. Ladder __________________ g. Octopus __________________

d. Kite __________________ h. Xylophone __________________

Total Score _________

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V. CONSTRUCTIONS

Screen: Visual Memory Present stimulus sheet for 10 seconds, then have patient draw the two figures from memory. Must be

perfect to pass. The examiner may wish to have patients who fail the screen to copy the two figures.

Pass Fail

Metric: Tile Designs Present the tiles and click the boxes to start and stop the timers. Click Y or N for correct. Scores are automatically calculated.

1. Design

2. Design

3. Design

Total Score _________

VI. MEMORY Four Word Memory Test (Part 2)

Answers can be recalled without prompting,

or recalled with category prompt,

or recognized only from a list.

Words Category Recognition Score

Total Score __________

Place tiles in front of patient as shown here:

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VII. CALCULATIONS

Screen: Pose the math question and start the timer. Stop the timer when answered. Enter the response. Click on Y or N. Scoring is automatic. Must be correct in 20 secs or less .

Response How much is 5 x 13?

Pass Fail

Metric: Problems may be repeated but time runs continously from first presentation.

Response

How much is 5 + 3?

How much is 15 + 7?

How much is 31 - 8?

How much is 39 ÷ 3?

Total Score _________

VIII. REASONING

A. Similarities: Explain: “A hat and coat are alike because they are both articles of clothing.” If patient does not respond, encourage; if patient gives differences, score 0. Screen: Painting & Music (Must be abstract—only “art,” ‘artist,” or “forms of art” are acceptable.)

____________________________________________________________________________________

Pass Fail

Metric: Answers are correct if fully abstract; imprecise if concrete; or incorrect. See Manual for examples.

Abstract Idea Other Responses

a. Rose-Tulip Flowers

b. Bicycle-Train Transportation

c. Watch-Ruler Measurement

d. Corkscrew-Hammer Tools

Total Score _________

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B. Judgment

Screen: What would do if you were stranded in an airport 1,000 miles from home, with only $1.00 in your pocket?

Pass Fail Metric: Score as correct, partially correct or incorrect. a. What would you do if you woke up one minute before 8:00 a.m. and remembered

that you had an important appointment downtown at 8:00 o’clock?

b. What would you do if you were walking beside a lake and saw that a

two year old child was playing alone at the end of a pier?

c. What would you do if you came home and found that a broken pipe was flooding the kitchen?

Total Score _________

IX. Patient’s Comments                                  Record patient's response verbatim

Was there anything that distracted you today or made it hard to concentrate? How do you feel you did on the questions today?

X. Examiner's Observations (see p 29 of the 2013 Cognistat Manual)

Cognitive Status Profile†

† THE VALIDITY OF THIS EXAMINATION DEPENDS ON ADMINISTRATION IN STRICT ACCORDANCE WITH THE 2013 COGNISTAT MANUAL. Note: Normal scores cannot be taken as evidence that brain pathology does not exist. Similarly, scores falling in the mild, moderateor severe range of impairment do not necessarily reflect brain dysfunction (see section of the Cognistat Manual entitled “Cautions in Interpretation”).

©Copyright 1983, 1988, 1995, 2001, 2007, 2009, 2010, 2011 and 2013. No portion of this test may be copied, duplicated or otherwise reproduced without the prior written consent of the copyright owner.

Cognistat Inc., Headquarters: 4480 Côte de Liesse, Suite #355, Montreal, QC, H4N 2R1 Canada

Phone: +1-(514)-337-7337 ● Fax: +1-(514)-336-6537 ● Web: www.cognistat.com California office: PO Box 460, Fairfax, CA 94978 ● Phone:+1-800-922-5840

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XI. Cognistat Summary