For further information on the Montreal Cognitive Assessment (MoCA) and completion guidelines refer to the protocol (Appendix 2: Healthcare Team Assessments and Appendix 3.2: Montreal Cognitive Assessment (MoCA) Guide) or www.mocatest.org. Note: a de-identified copy of the MoCA form is required to be uploaded for each assessment completed.
Date evaluation completed:
Enter the date the evaluation was completed in DD/MMM/YYYY format.
Evaluation administered by:
Enter first and last name of health care team member administering the assessment (up to 100 characters).
Visit type
This field is requires for all assessments conducted after April 14, 2020. Indicate the type of visit from the options available:
- In-person
- Remote: audio-visual teleconference
- Remote: telephone
Visuospatial/Executive
Visuospatial/Executive total points:
Report the total points the subject achieved on the visuospatial/executive assessment out of five points.
Naming
Naming total points:
Report the total points the subject achieved on the naming assessment out of three points.
Memory
Memory trial 1 complete:
Indicate “Yes” or “No” if the first memory trial was completed. No points are given for Trials 1 and 2.
Memory trial 2 complete:
Indicate “Yes” or “No” if the second memory trial was completed. No points are given for Trials 1 and 2.
Attention
Read list of digits (1 digit/second) total points:
Report the total points the subject achieved on the digit assessment out of two points.
Read list of letters (no points if greater than 2 errors) total points:
Report the total points the subject achieved on the letter assessment out of one point. Per protocol, allocate one point for repeating the sequence correctly. If greater than two errors, no points will be allocated.
Serial 7 Subtraction:
Report the total points the subject achieved on the Serial 7 Subtraction assessment out of three points.
Attention total points:
Attention assessment total points is a system-generated determination. No response is required.
Language
Repeat total points:
Report the total points the subject achieved on the repeat assessment out of two points.
Fluency/Name total points:
Report the total points the subject achieved on the fluency/name assessment out of one point.
Abstraction total points:
Report the total points the subject achieved on the abstraction assessment out of two points.
Delayed recall total points:
Report the total points the subject achieved on the delayed recall assessment out of five points.
Orientation total points:
Report the total points the subject achieved on the orientation assessment out of six points.
Add 1 point if the subject has ≤ 12 years of formal education
If the subject has ≤ 12 years of formal education add one point to the total points.
Total points:
Language assessment total points is a system-generated determination. No response is required.
MoCA form – de-identified (required):
Upload a copy of the de-identified MoCA form (pdf, doc, or docx format.)
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