Clinical Scales
APGAR
Sign012
Appearance (color)
Blue or pale
Pink body with blue extremities
Completely pink
Pulse (heart rate)
Absent
Slow (<100/min)
>100/min
Grimace (reflex irritability)
No response
Grimace
Cough or sneeze
Activity (muscle tone)
Limp
Some flexion
Active movement
Respirations
Absent
Slow, irregular
Good, crying
Total APGAR Score:
Glasgow Coma Scale (GCS)
ParameterResponseScore
EyesOpen Spontaneously4
To verbal command3
To pain2
No response1
Best motor responseTo verbal command Obeys6
To painful stimulusLocalizes pain5
Flexion-withdrawal4
Decorticate (flex)3
Decerebrate (extend)2
No response1
Best verbal response Oriented, converses5
Disoriented, converses4
Inappropriate responses3
Incomprehensible sounds2
No response1
Total GCS Score:
Mini Mental Status Exam (MMSE)
CategoryQuestionScore
Orientation What is the year?
1 point if correct:
What is the season?
1 point if correct:
What is the date (#)?
1 point if correct:
What is the weekday?
1 point if correct:
What is the month?
1 point if correct:
What state are you in?
1 point if correct:
What county are you in?
1 point if correct:
What town are you in?
1 point if correct:
What building are you in?
1 point if correct:
What floor are you on?
1 point if correct:
Registration Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat until all 3 are learned.
None registered:
One registered:
Two registered:
Three registered:
Attention & Calculation Serial 7's - starting with 100, subtract 7 repeatedly. Stop after 5 answers. Alternatively, spell "WORLD" backward.
93 / D
86 / L
79 / R
72 / O
65 / W
Recall Ask for the three objects named above. Give one point for each correct answer.
None recalled:
One recalled:
Two recalled:
Three recalled:
Language Point to a pencil and have the patient name it.
1 point if correct:
Point to a watch and have the patient name it.
1 point if correct:
Have the patient repeat the phrase "No if's, and's, or but's."
1 point if correct:
Have the patient follow a three-stage command: Take a paper in your right hand, fold it in half, and put it on the floor."
No stages followed:
1 stage followed:
2 stages followed:
3 stages followed:
Give the patient a piece of paper with the following instructions on it, and ask the patient to read and obey the instructions.
  • Close your eyes.
  • Write a sentence.
  • Copy this design.
No commands followed:
1 command followed:
2 commands followed:
3 commands followed:
Total MMSE Score:
Subscores:
Orientation:
Registration:
Attention & Calculation:
Recall:
Language: