Brief Cognitive Assessment Tool®Short Form (BCAT®-SF)

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Brief Cognitive Assessment Tool?Short Form (BCAT?-SF)

Name: ______________________________________________________ Today's Date: _____________________________________________

DOB: _________________________________________________________

Gender: Female / Male

Total Score: ____________________________ / 21

Education: ______________________________________________

Cut Score: 15/16 (dementia < 15; non-dementia > 16)

Examiner: ______________________________________________

ORIENTATION Year Month

Day/Week

State

City

Situation

POINTS _______ / 6

IMMEDIATE VERBAL RECALL Banana Justice Sara

Bridge

_______ / 4

IMMEDIATE STORY RECALL

(Instructions: X > 8 = 2 points, X = 4-7 = 1 point, X < 3 = 0 points)

_______ / 11

Carol / borrowed / $10 / from her brother / Jack / last week. / She couldn't pay him back / because she bought / a delicious / ice cream cone / at the circus instead.

EXECUTIVE

Cognitive Shifting: (Instructions: X > 8 = 2 points, X = 6-7 = 1 point, X < 5 = 0 points) 1A - 2B - 3C - 4D - 5E - 6F - 7G - 8H - 9I - 10J

_______ / 2 _______ / 2

DELAYED STORY RECALL

(Instructions: X > 8 = 2 points, X = 4-7 = 1 point, X < 3 = 0 points)

_______ / 11

Carol / borrowed / $10 / from her brother / Jack / last week. / She couldn't pay him back / because she bought / a delicious / ice cream cone / at the circus instead.

_______ / 2

STORY RECOGNITION What was the name of the woman who borrowed money? How much money did she borrow? What was the name of the woman's brother? What did the woman buy? Where did the woman go?

Carol $15 Robert Ice Cream Mall

Mary $10 Tom Sandwich Circus

Sue $16 Jack Soda Grocery

_______ / 5

?

?.

These results are based on the inputting of BCAT?-SF item scores. The conclusions reported are the result of statistical analyses from data collected from psychometric research.

All results are based on statistical probabilities, not certainties. Mansbach Health Tools, LLC is not responsible for formal diagnoses or treatments.

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