1) Orientation
Month:	0 1

Date: 0 1

Day of week:	0 1

Year: 	0 1

Time (within 1 hr.):	0 1

Orientation Total Score	/5

2) Immediate Memory: (all 3 trials are completed regardless of score on trial 1 & 2; total score equals sum across all 3 trials)

List	Trial 1	Trial 2	
Trial 3

Word 1	0    1	0    1	0    1
Word 2	0    1	0  1	0  1
Word 3	0  1	0  1	0  1
Word 4	0  1	0  1	0  1
Word 5	0  1	0  1	0  1
Total	 	 	 
Immediate Memory Total Score____/ 15

(Note: Subject is not informed of Delayed Recall testing of memory)

NEUROLOGICAL SCREENING:

Loss of Consciousness: (occurrence, duration)

Retrograde and & Posttraumatic Amnesia: 
(recall of events pre- and post-injury)

Strength:

Sensation:

Coordination:

3)Concentration:

Digits Backward (If correct, go to next string length.
If incorrect, read trial 2. Stop after incorrect on both trials)

4-9-3	6-2-9	_________0  1
3-8-1-4	3-2-7-9	_________0  1
6-2-9-7-1	1-5-2-8-6	_________0  1
7-1-8-4-6-2	5-3-9-1-4-8	_________0  1
Months in reverse order: (entire sequence correct for 1 point)
Dec-Nov-Oct-Sep-Aug-Jul
Jun-May-Apr-Mar-Feb-Jan_________0 1

Concentration Total Score________/ 5

Exertional Maneuvers
(when appropriate):

5 jumping jacks
5 push-ups
5 sit-ups
5 knee-bends

4) Delayed Recall

Word 101
Word 201
Word 301
Word 401
Word 501

Delayed Recall Total Score ______/ 5

Summary of Total Scores:

Orientation_______________/ 5 
Immediate Memory_________/ 1
Concentration_____________/ 5
Delayed Recall_____________/ 5

Overall Total Score_______/30

http://www.cdc.gov/ncipc/pub-res/tbi_toolkit/mccrae/results.htm