1c clinical notes mini mental exam form 2025

1. Click ‘Get Form’ to open the 1c clinical notes mini mental exam form in the editor.
2. Begin by entering the date, hospital number, name, birth date, and address at the top of the form. If not pre-printed, ensure these details are filled out clearly.
3. Proceed to section 1 where you will answer questions about the year, season, date, day, and month. Fill in each blank accurately.
4. In section 2, identify your location by filling in the state, county, town, hospital, and floor.
5. For section 3, name three objects: orange, airplane, and tobacco. Make sure to note any trails as indicated.
6. Complete section 4 by performing serial sevens or spelling 'world' backwards as instructed.
7. Recall the three objects listed earlier in section 5 and write them down.
8. In sections 6 through 10, follow instructions to name items (pencil and watch), read a command, copy a design, write a sentence, and repeat a phrase.
9. Finally, follow the three-stage command in section 11 carefully to complete your assessment.

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