brief cognitive assessment tool®short form (bcat®-sf)...banana justice sara bridge brief cognitive...

Name: ______________________________________________________ DOB: _________________________________________________________ Gender: Female / Male Education: ______________________________________________ Examiner: ______________________________________________ ORIENTATION Year Month Day/Week State City Situation IMMEDIATE VERBAL RECALL Banana Justice Sara Bridge Brief Cognitive Assessment Tool® Short Form (BCAT®-SF) Today’s Date: _____________________________________________ Total Score: ____________________________ / 21 Cut Score: 15/16 (dementia < 15; non-dementia > 16) IMMEDIATE STORY RECALL (Instructions: X > 8 = 2 points, X = 4-7 = 1 point, X < 3 = 0 points) Carol / borrowed / $10 / from her brother / Jack / last week. / She couldn't pay him back / because she bought / a delicious / ice cream cone / at the circus instead. EXECUTIVE Cognitive Shifting: (Instructions: X > 8 = 2 points, X = 6-7 = 1 point, X < 5 = 0 points) 1A - 2B - 3C - 4D - 5E - 6F - 7G - 8H - 9I - 10J POINTS _______ / 6 _______ / 4 _______ / 2 DELAYED STORY RECALL (Instructions: X > 8 = 2 points, X = 4-7 = 1 point, X < 3 = 0 points) Carol / borrowed / $10 / from her brother / Jack / last week. / She couldn't pay him back / because she bought / a delicious / ice cream cone / at the circus instead. STORY RECOGNITION What was the name of the woman who borrowed money? How much money did she borrow? What was the name of the woman’s brother? What did the woman buy? Where did the woman go? Carol $15 Robert Ice Cream Mall Mary $10 Tom Sandwich Circus Sue $16 Jack Soda Grocery _______ / 2 _______ / 11 _______ / 2 _______ / 11 _______ / 5 These results are based on the inputting of BCAT ® -SF item scores. The conclusions reported are the result of statistical analyses from data collected from psychometric research. All results are based on statistical probabilities, not certainties. Mansbach Health Tools, LLC is not responsible for formal diagnoses or treatments. ®. ® BCAT® All Rights Reserved. | William Mansbach, Ph.D. 7067 Columbia Gateway Drive Suite 180 Columbia, MD 21046 e: [email protected] e-fax: 855.850.8661 w: thebcat.com

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Page 1: Brief Cognitive Assessment Tool®Short Form (BCAT®-SF)...Banana Justice Sara Bridge Brief Cognitive Assessment Tool®Short Form (BCAT®-SF) Today’s Date: _____ Total Score: _____

Name: ______________________________________________________

DOB: _________________________________________________________

Gender: Female / Male

Education: ______________________________________________

Examiner: ______________________________________________

ORIENTATION

Year Month Day/Week State City Situation

IMMEDIATE VERBAL RECALL

Banana Justice Sara Bridge

Brief Cognitive Assessment Tool® Short Form (BCAT®-SF)

Today’s Date: _____________________________________________

Total Score: ____________________________ / 21

Cut Score: 15/16 (dementia < 15; non-dementia > 16)

IMMEDIATE STORY RECALL

(Instructions: X > 8 = 2 points, X = 4-7 = 1 point, X < 3 = 0 points)

Carol / borrowed / $10 / from her brother / Jack / last week. / She couldn't pay him back / because she bought / a delicious / ice cream cone / at the circus instead.

EXECUTIVE

Cognitive Shifting: (Instructions: X > 8 = 2 points, X = 6-7 = 1 point, X < 5 = 0 points) 1 A - 2 B - 3 C - 4 D - 5 E - 6 F - 7 G - 8 H - 9 I - 1 0 J

POINTS

_______ / 6

_______ / 4

_______ / 2

DELAYED STORY RECALL

(Instructions: X > 8 = 2 points, X = 4-7 = 1 point, X < 3 = 0 points)

Carol / borrowed / $10 / from her brother / Jack / last week. / She couldn't pay him back / because she bought / a delicious / ice cream cone / at the circus instead.

STORY RECOGNITION

What was the name of the woman who borrowed money?

How much money did she borrow?

What was the name of the woman’s brother?

What did the woman buy?

Where did the woman go?

Carol

$15

Robert

Ice Cream

Mall

Mary

$10

Tom

Sandwich

Circus

Sue

$16

Jack

Soda

Grocery

_______ / 2_______ / 11

_______ / 5

These results are based on the inputting of BCAT® -SF item scores. The conclusions reported are the result of statistical analyses from data collected from psychometric research. All results are based on statistical probabilities, not certainties. Mansbach Health Tools, LLC is not responsible for formal diagnoses or treatments.

®. ®

7067 Columbia Gateway DriveSuite 180Columbia, MD 21046

e: [email protected]: 855.850.8661w: thebcat.com

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