015 COGNISTAT ACTIVE FORM

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 Past Psychiatric History

2 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

3 _____ _____ Fatigue _____ _____ English as a 2nd Language _____ _____ Learning Disorder _____ _____ ADHD _____ _____ COGNISTAT Inc. 2015 Page 1 of 8 Litigation _____ _____ COGNISTAT Inc. 2015 Page 2 of 8 I. LEVEL OF CONSCIOUSNESS: Alert Lethargic Fluctuating II.

4 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.

5 ATTENTION 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 AnswersRobin Carrot Piano Green IV.

6 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 ( 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.

7 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 Inc.

8 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.

9 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.

10 Shoe _____ e. Horseshoe _____ b. Bus _____ f. Anchor _ _____ c. Ladder _____ g. Octopus _____ d. Kite _____ h. Xylophone _____ Total Score _____ 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 .