POINTS

TOTAL

M E M O R Y

N A M I N G

VISUOSPATIAL / EXECUTIVE

ATTENTION

LANGUAGE

ABSTRACTION

DELAYED RECALL

ORIENTATION

Read list of words, subject must repeat them. Do 2 trials. Do a recall after 5 minutes.

Subject has to repeat them in the forward order [ ] 2 1 8 5 4 Subject has to repeat them in the backward order [ ] 7 4 2

Read list of letters. The subject must tap with his hand at each letter A. No points if ≥ 2 errors

[ ] F B A C M N A A J K L B A F A K D E A A A J A M O F A A B

Serial 7 subtraction starting at 100 [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65

Repeat : I only know that John is the one to help today. [ ]The cat always hid under the couch when dogs were in the room. [ ]

Similarity between e.g. banana - orange = fruit [ ] train – bicycle [ ] watch - ruler

Draw CLOCK (Ten past eleven)Copy cube

__/5

__/3

No points

1st trial

2nd trial

FACE VELVET CHURCH DAISY RED

__/5

__/2

__/1

__/3

__/2

Fluency / Name maximum number of words in one minute that begin with the letter F _____ [ ] (N ≥ 11 words) __/1

__/2

__/6

__/30

B

Begin

End5

E

1

A

2

4 3

C

D

Read list of digits (1 digit/ sec.).

NAME :Education :

Sex :Date of birth :

DATE :

© Z.Nasreddine MD Version November 7, 2004

www.mocatest.orgNormal ≥ 26 / 30

Add 1 point if ≤ 12 yr edu

MONTREAL COGNITIVE ASSESSMENT (MOCA)

[ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City

[ ]Contour

[ ][ ] [ ]Numbers

[ ]Hands

[ ] [ ] [ ]

4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2 pts, 1 correct: 1 pt, 0 correct: 0 pt

( 3 points )

Category cue

Points for UNCUED

recall onlyWITH NO CUE

Optional

Has to recall words

Multiple choice cue

FACE VELVET CHURCH DAISY RED [ ] [ ] [ ] [ ] [ ]

In It Ial V Is It Packet NACC UNiform DAtA Set (UDS)

UDS Version 3.0, March 2015 National Alzheimer’s Coordinating Center | (206) 543-8637 | fax: (206) 616-5927 | naccmail@uw.edu | www.alz.washington.edu Page 1 of 1

ADC name: Subject ID: Form date: / / Visit #: Examiner’s initials:

In the past four weeks, did the subject have difficulty or need help with: Not applicable (e.g., never did) Normal

Has difficulty, but does by self

Requires assistance Dependent Unknown

1. Writing checks, paying bills, or balancing a checkbook 8 0 1 2 3 9

2. Assembling tax records, business affairs, or other papers 8 0 1 2 3 9

3. Shopping alone for clothes, household necessities, or groceries 8 0 1 2 3 9

4. Playing a game of skill such as bridge or chess, working on a hobby 8 0 1 2 3 9

5. Heating water, making a cup of coffee, turning off the stove 8 0 1 2 3 9

6. Preparing a balanced meal 8 0 1 2 3 9

7. Keeping track of current events 8 0 1 2 3 9

8. Paying attention to and understanding a TV program, book, or magazine 8 0 1 2 3 9

9. Remembering appointments, family occasions, holidays, medications 8 0 1 2 3 9

10. Traveling out of the neighborhood, driving, or arranging to take public transportation

8 0 1 2 3 9

INSTRUCTIONS: This form is to be completed by the clinician or other trained health professional, based on information provided by the co-participant. For further information, see UDS Coding Guidebook for Initial Visit Packet, Form B7. Indicate the level of performance for each activity by checking the one appropriate response.

Form B7: Functional assessment NACC Functional Assessment Scale (FAS1)

1Adapted from table 4 of Pfeffer RI, Kurosaki TT, Harrah CH, et al. Measurement of functional activities of older adults in the community. J Gerontol 37:323–9, 1982. Copyright© 1982. The Gerontological Society of America. Reproduced by permission of the publisher.

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)DATE:NAME:Over the last 2 weeks, how often have you beenbothered by any of the following problems? Not at all Severaldays More thanhalf thedays Nearlyevery day(use "ⁿ" to indicate your answer) 0 1 2 3Little interest or pleasure in doing things1. 0 1 2 3Feeling down, depressed, or hopeless2. 0 1 2 3Trouble falling or staying asleep, or sleeping too much3. 0 1 2 3Feeling tired or having little energy4. 0 1 2 3Poor appetite or overeating5. 0 1 2 3Feeling bad about yourself or that you are a failure orhave let yourself or your family down6. 0 1 2 3Trouble concentrating on things, such as reading thenewspaper or watching television7. 0 1 2 3Moving or speaking so slowly that other people couldhave noticed. Or the opposite being so figety orrestless that you have been moving around a lot morethan usual8. 0 1 2 3Thoughts that you would be better off dead, or ofhurting yourself9. add columns + +TOTAL:(Healthcare professional: For interpretation of TOTAL,please refer to accompanying scoring card). Not difficult at allIf you checked off any problems, how difficulthave these problems made it for you to doyour work, take care of things at home, or getalong with other people?10. Somewhat difficultVery difficultExtremely difficultCopyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc.A2663B 10-04-2005

PHQ-9 Patient Depression Questionnaire For initial diagnosis:

1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 s in the shaded section (including Questions #1 and #2), consider a depressive

disorder. Add score to determine severity.

Consider Major Depressive Disorder

- if there are at least 5 s in the shaded section (one of which corresponds to Question #1 or #2) Consider Other Depressive Disorder

- if there are 2-4 s in the shaded section (one of which corresponds to Question #1 or #2) Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. To monitor severity over time for newly diagnosed patients or patients in current treatment for depression:

1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment.

2. Add up s by column. For every : Several days = 1 More than half the days = 2 Nearly every day = 3

3. Add together column scores to get a TOTAL score.

4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.

5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention.

Scoring: add up all checked boxes on PHQ-9 For every Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Interpretation of Total Score

Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression

10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc. A2662B 10-04-2005

WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0

Page 1 of 4 (36-item, self-administered)

36-item version, self-administeredThis questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.

Please continue to next page …

In the past 30 days, how much difficulty did you have in:

Understanding and communicating

D1.1 Concentrating on doing something for ten minutes?

None Mild Moderate Severe Extreme or cannot do

D1.2 Remembering to do important things? None Mild Moderate Severe Extreme or cannot do

D1.3 Analysing and finding solutions to problems in day-to-day life?

None Mild Moderate Severe Extreme or cannot do

D1.4 Learning a new task, for example, learning how to get to a new place?

None Mild Moderate Severe Extreme or cannot do

D1.5 Generally understanding what people say? None Mild Moderate Severe Extreme or cannot do

D1.6 Starting and maintaining a conversation? None Mild Moderate Severe Extreme or cannot do

Getting around

D2.1 Standing for long periods such as 30 minutes?

None Mild Moderate Severe Extreme or cannot do

D2.2 Standing up from sitting down? None Mild Moderate Severe Extreme or cannot do

D2.3 Moving around inside your home? None Mild Moderate Severe Extreme or cannot do

D2.4 Getting out of your home? None Mild Moderate Severe Extreme or cannot do

D2.5 Walking a long distance such as a kilometre [or equivalent]?

None Mild Moderate Severe Extreme or cannot do

WHODAS-03(23Nov09).book Page 1 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0

Page 2 of 4 (36-item, self-administered)

36

Self

Please continue to next page …

In the past 30 days, how much difficulty did you have in:

Self-care

D3.1 Washing your whole body? None Mild Moderate Severe Extreme or cannot do

D3.2 Getting dressed? None Mild Moderate Severe Extreme or cannot do

D3.3 Eating? None Mild Moderate Severe Extreme or cannot do

D3.4 Staying by yourself for a few days? None Mild Moderate Severe Extreme or cannot do

Getting along with people

D4.1 Dealing with people you do not know? None Mild Moderate Severe Extreme or cannot do

D4.2 Maintaining a friendship? None Mild Moderate Severe Extreme or cannot do

D4.3 Getting along with people who are close to you?

None Mild Moderate Severe Extreme or cannot do

D4.4 Making new friends? None Mild Moderate Severe Extreme or cannot do

D4.5 Sexual activities? None Mild Moderate Severe Extreme or cannot do

Life activities

D5.1 Taking care of your household responsibilities?

None Mild Moderate Severe Extreme or cannot do

D5.2 Doing most important household tasks well?

None Mild Moderate Severe Extreme or cannot do

D5.3 Getting all the household work done that you needed to do?

None Mild Moderate Severe Extreme or cannot do

D5.4 Getting your household work done as quickly as needed?

None Mild Moderate Severe Extreme or cannot do

WHODAS-03(23Nov09).book Page 2 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0

Page 3 of 4 (36-item, self-administered)

36

Self

If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5–D5.8, below. Oth-erwise, skip to D6.1.

Please continue to next page …

Because of your health condition, in the past 30 days, how much difficulty did you have in:

D5.5 Your day-to-day work/school? None Mild Moderate Severe Extreme or cannot do

D5.6 Doing your most important work/school tasks well?

None Mild Moderate Severe Extreme or cannot do

D5.7 Getting all the work done that you need to do?

None Mild Moderate Severe Extreme or cannot do

D5.8 Getting your work done as quickly as needed?

None Mild Moderate Severe Extreme or cannot do

Participation in society

In the past 30 days:

D6.1 How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

None Mild Moderate Severe Extreme or cannot do

D6.2 How much of a problem did you have because of barriers or hindrances in the world around you?

None Mild Moderate Severe Extreme or cannot do

D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others?

None Mild Moderate Severe Extreme or cannot do

D6.4 How much time did you spend on your health condition, or its consequences?

None Mild Moderate Severe Extreme or cannot do

D6.5 How much have you been emotionally affected by your health condition?

None Mild Moderate Severe Extreme or cannot do

D6.6 How much has your health been a drain on the financial resources of you or your family?

None Mild Moderate Severe Extreme or cannot do

D6.7 How much of a problem did your family have because of your health problems?

None Mild Moderate Severe Extreme or cannot do

D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure?

None Mild Moderate Severe Extreme or cannot do

WHODAS-03(23Nov09).book Page 3 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0

Page 4 of 4 (36-item, self-administered)

36

Self

This completes the questionnaire. Thank you.

H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ____

H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?

Record number of days ____

H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?

Record number of days ____

WHODAS-03(23Nov09).book Page 4 Tuesday, November 24, 2009 1:30 PM