| Orientation (1 point each) | | Month | | Date | | Day of week | | Year | | Time (within 1 hr) | | Orientation score: 5 | | Immediate memory (1 point for each correct, total over 3 trials) | | | Trial 1 | Trial 2 | Trial 3 | | Word 1 | | | | | Word 2 | | | | | Word 3 | | | | | Word 4 | | | | | Word 5 | | | | | Immediate memory score: 15 | | Concentration | | Reverse digits (Go to next string length if correct on first trial. Stop if incorrect on both trials. 1 point each for each string length.) | | 3-8-2 | 5-1-8 | | 2-7-9-3 | 2-1-6-8 | | 5-1-8-6-9 | 9-4-1-7-5 | | 6-9-7-3-5-1 | 4-2-8-9-3-7 | | Months of the year in reverse order (1 point for entire sequence correct) | | Dec-Nov-Oct-Sep-Aug-Jul | | Jun-May-Apr-Mar-Feb-Jan | | Concentration score: 5 | | | Delayed recall (Approximately 5 minutes after Immediate memory. 1 point each.) | | Word 1 | | Word 2 | | Word 3 | | Word 4 | | Word 5 | | Delayed recall score: 5 | | Summary of total scores: | | Orientation | 5 | | Immediate memory | 15 | | Concentration | 5 | | Delayed recall | 5 | | Total score | 30 | | The following may be performed between the Immediate memory and Delayed recall portions of this assessment when appropriate: | | Neurologic screening | | Recollection of the injury | | Strength | | Coordination | | Exertional maneuvers | | 1 40-yard sprint | | 5 sit-ups | | 5 push-ups | | 5 knee bends | |
