Page 1
2015 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 ____________________ ________________________
Cognistat Inc. © 2015 Page 1 of 8
Litigation ____________________ ________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
L R
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
mmm dd, yyyy
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
if any
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
mmm dd, yyyy
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Page 2
Cognistat Inc. © 2015 Page 2 of 8
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
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
_________________________________________________________________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
__________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Incorrect
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Page 3
Cognistat Inc. © 2015 Page 3 of 8
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.
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Select Word Group A, B or C
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
___________________________
Rflanagan
Typewritten Text
___________________________
Rflanagan
Typewritten Text
___________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
___________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Show Hide
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Correct
Rflanagan
Typewritten Text
Incorrect
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Clock
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Page 4
Cognistat Inc. © 2015 Page 4 of 8
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 _________
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
1st Attempt Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
2nd Attempt Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Pass
Rflanagan
Typewritten Text
Fail
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Incorrect
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Page 5
Cognistat Inc. © 2015 Page 5 of 8
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:
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Time (Mins)
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Start Stop
Rflanagan
Typewritten Text
Click Box for Elapsed Time
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Word Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Category Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Recognition Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Incorrect
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Time (secs)
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Page 6
Cognistat Inc. © 2015 Page 6 of 8
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 _________
Rflanagan
Typewritten Text
Start Stop
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Start Stop
Rflanagan
Typewritten Text
Y N
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
________
Rflanagan
Typewritten Text
___________
Rflanagan
Typewritten Text
___________
Rflanagan
Typewritten Text
___________
Rflanagan
Typewritten Text
___________
Rflanagan
Typewritten Text
________________________________
Rflanagan
Typewritten Text
________________________________
Rflanagan
Typewritten Text
________________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Time (secs)
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Time (secs)
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
________________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Correct
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Imprecise
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Incorrect
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Page 7
Cognistat Inc. © 2015 Page 7 of 8
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)
Rflanagan
Typewritten Text
___________________________________________________________________________________________________________
Rflanagan
Typewritten Text
___________________________________________________________________________________________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________
Rflanagan
Typewritten Text
___________________________________________________________________________________________________________________
Rflanagan
Typewritten Text
___________________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________________
Rflanagan
Typewritten Text
_____________________________________________________________________________________________________________
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
(re: attitude, fatigue, cooperation, awareness, irritability, etc.)
Rflanagan
Typewritten Text
Page 8
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, 2013, 2014 and 2015. 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
Cognistat Inc. © 2015 Page 8 of 8
XI. Cognistat Summary
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text
(0 to 6)
Rflanagan
Typewritten Text
Rflanagan
Typewritten Text