16) Can you tell me the days of the week backwards, starting with Saturday? (S,F,T,W,T,M,S)
Enter number representing longest correct consecutive series of days
	0 refused			_____
				80
17) Can you tell me the months of the year backwards, starting with December? (D,N,O,S,A,J,J,M,A,M,F,J)
Enter number representing longest correct consecutive series of months
	0 refused			_____   _____
				81         82

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End of Patient Questions

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Thank you. Is there anything else you want to tell me, or anything you want to ask me?

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Observations

Form ___ ___ Study ID ___ ___ ___ ___
             3                          

Hosp. Unit # ___ ___ ___ ___ ___
7                                  

Evaluation # ___ ___
13         

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18) Did the patient stare into space and appear unaware of his/her environment? If present, how much of the time?
1 Never	2 Rarely	3 Sometimes	4 Most of the Time	_____
				15
19) Did the patient talk about something else, for example, change the subject suddenly (e.g., non-sequitur) or tell a story unrelated to the interview? (Tangential)
1 No	2 Mild	3 Moderate	4 Severe	_____
				16
20) Did the patient appear inappropriately distracted by environmental stimuli, for example, respond to questions asked of roommate? (Distractible) If present, how much of the time?
1 Never	2 Rarely	3 Sometimes	4 Most of the Time	_____
				17
21) Did the patient show excessive absorption with ordinary objects in the environment, for example, repetitively fold sheets or examine the TV tube over and over? (Hypervigilant)
1 No	2 Mild	3 Moderate	4 Severe	_____
				18
22) Did the patient have a recurring thought that prevented him/her from responding appropriately to the environment, for example, continuously look for shoes that weren't there? (Persistent Thought)
1 No	2 Mild	3 Moderate	4 Severe	_____
				19
23) Did the patient have trouble keeping track of what was being said during the interview, for example, fail to follow instructions or answer questions one at a time? (Inattentive) If present, how much of the time?
1 Never	2 Rarely	3 Sometimes	4 Most of the Time	_____
				20
24) Did the patient appear inappropriately startled by stimuli in the environment?
1 No	2 Mild	3 Moderate	4 Severe	_____
				21
25) Did the patient's level of consciousness fluctuate during the interview, for example, start to respond appropriately and then drift off?
1 No	2 Mild	3 Moderate	4 Severe	_____
				22
26) Was the patient
1 Awake	2 Sleepy	3 Stuporous	4 Comatose	_____
				23

 

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Notes on behavior:

 

Disturbance of Consciousness Score_____
24    

1= Not Present
2= Present
Present: 2-4 on items #18-25

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If the patient is non-communicative, answer all questions on this page with a code of 7 (Not Applicable) and go on to Page 11.

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