*If you are reading this, either you are worried you have dementia, or you are worried your loved one might. To be most accurate, you should help the other person with directions but in NO WAY the actual answers. Sometimes if we are having trouble we get frustrated and cheat or give up. If you have to cheat or give up... you failed. So don't do either, take your time, and forge ahead.*

*How Well Are You Thinking?*

*Self-Administered Gerocognitive Examination (SAGE)*

Name________________________________________________________
Date of Birth ______/______/_____

How far did you get in school?
_____________________________________ I am a Man______ Woman______

I am Asian__________
Black__________ Hispanic__________ White__________ Other__________

Have you had any problems with
memory or thinking? Yes________ Only Occasionally________ No________

Have you had any blood relatives
that have had problems with memory or thinking? Yes________ No________

Do you have balance problems?
Yes________ No________

If yes, do you know the cause?
Yes (specify reason)_______________________________ No________

Have you ever had a major stroke?
Yes________ No________ A minor or mini-stroke? Yes______ No________

Do you currently feel sad or
depressed? Yes________ Only Occasionally________ No________

Have you had any change in your
personality? Yes (specify changes)________________________ No________

Do you have more difficulties
doing everyday activities due to thinking problems? Yes________ No________

**1. What is today’s date?**(from memory – no cheating!) Month___________ Date_______ Year_________

**2. Name the following pictures**(don’t worry about spelling):

Answer these questions:

3. How are a watch and a ruler similar? Write down how they are alike. They both are… what?

________________________________________________________________________________

4. How many nickels are in 60 cents? ___________________________

5. You are buying $13.45 of groceries. How much change would you receive back from a $20 bill?

___________________________________________________________________________________

6. Memory Test (memorize these instructions). Do later only after completing this entire test:

At the bottom of the very last page: Write “I am done” on the blank line provided.

3. How are a watch and a ruler similar? Write down how they are alike. They both are… what?

________________________________________________________________________________

4. How many nickels are in 60 cents? ___________________________

5. You are buying $13.45 of groceries. How much change would you receive back from a $20 bill?

___________________________________________________________________________________

6. Memory Test (memorize these instructions). Do later only after completing this entire test:

At the bottom of the very last page: Write “I am done” on the blank line provided.

7. Copy this picture:

8. Drawing test

- Draw a large face of a clock and place in the numbers

- Position the hands for 5 minutes after 11 o’clock

- On your clock, label “L” for the long hand and “S” for the short hand

- Draw a large face of a clock and place in the numbers

- Position the hands for 5 minutes after 11 o’clock

- On your clock, label “L” for the long hand and “S” for the short hand

9. Write down the names of 12 different animals (don’t worry about spelling):

_________________ _________________ _________________ _________________

_________________ _________________ _________________ _________________

_________________ _________________ _________________ _________________

Review this example (this first one is done for you) then go to question 10 below:

Draw a line from one circle to another starting at 1 and alternating numbers and letters (1 to A to 2 to B to 3 to C).

Draw a line from one circle to another starting at 1 and alternating numbers and letters (1 to A to 2 to B to 3 to C).

10. Do the following: Draw a line from one circle to another starting at 1 and alternating numbers and letters

in order before ending at F (1 to A to 2 to B and so on).

in order before ending at F (1 to A to 2 to B and so on).

Review this example (this first one is done for you) then answer question 11 below:

- Beginning with 1 triangle and 1 square

- Move 2 lines (marked with an X)

- To make 2 squares and no triangle

- Each line must be part of a complete square (no extra lines)

- Beginning with 1 triangle and 1 square

- Move 2 lines (marked with an X)

- To make 2 squares and no triangle

- Each line must be part of a complete square (no extra lines)

11. Solve the following problem:

- Beginning with 2 squares and 2 triangles

- Move 4 lines (mark with an X)

- To make 4 squares and no triangles

- Each line must be part of a complete square (no extra lines)

- Beginning with 2 squares and 2 triangles

- Move 4 lines (mark with an X)

- To make 4 squares and no triangles

- Each line must be part of a complete square (no extra lines)

12. Have you finished? ___________________________________

___________________________________________________________________________________

____________________________________________________________________________________

_____________________________________________________________________________________

___________________________________________________________________________________

How to score the results: (farther down is what the results mean)

Self-Administered Gerocognitive Examination (SAGE)

Average time to complete the test is 15 minutes.

Average time to complete the test is 15 minutes.

The maximum score is 22. A score of 17 and above is considered normal.

Administration:

The test is self-administered. It should be filled out in ink without the assistance of others.

Calendars and clocks should not be available during the testing.

Do not answer specific questions. Just say, “Do the best that you can”.

**Non-Scored Items:**

Demographics

Insight: Have you had any problems with memory or thinking?

Family History

Motor symptoms

Stroke symptoms

Depression symptoms

Personality changes

Functional abilities

Demographics

Insight: Have you had any problems with memory or thinking?

Family History

Motor symptoms

Stroke symptoms

Depression symptoms

Personality changes

Functional abilities

**Scored Items:**

**1. Orientation: Total possible points are 4**

Month: 1 = Correct

0 = Incorrect

**Date: 2 = exact**

1 = ± 3 days

0 = All else

Year: 1 = Correct

0 = Incorrect

**2. Naming: Total possible points are 2. Correct spelling not required.**

Each Picture: 1 = Correct

0 = Incorrect

**3. Similarities: Total possible points are 2. Correct spelling/grammar not required.**

2 = Abstract

1 = Concrete

0 = All else

**4. Calculation: Total possible point is 1.**

1 = Correct

0 = Incorrect

**5. Calculation: Total possible point is 1.**

1 = Correct

0 = Incorrect

**6. Memory: Points given below in twelve.**

**7. Construction: Total possible points are 2.**

3-D figure: 2 = 3-D, parallel lines within 10° and correct shape

1 = 3-D but lines not parallel within 10° or otherwise

incorrect shape

0 = All else

**8. Construction: Total possible points are 2.**

Clock: 4 components: Clock face, clock numbers (all 12 numbers in

correct order clockwise and approximately correct quadrant

position), hand positions (hands to correct time and must be joined

near clock center), and hand size (actual or if labeled correctly)

2 = 4 of 4 components correct

1 = 3 of 4 components correct; one of the three correct

components must be hand positions

0 = All else

**9. Verbal fluency: Total possible points are 2. Correct spelling not required.**

2 = 12 different items listed

1 = 10 or 11 different items listed

0 = 9 or less different items listed

**10. Executive: Total possible points are 2.**

Modified Trails: An error is if two items that should be connected are not or if two

items that should not be connected are.

2 = Perfect or self-corrected errors only

1 = 1 or 2 errors

0 = More than 2 errors

**11. Executive: Total possible points are 2.**

**Problem solving: Forms 1 and 2:**

2 = Correct lines moved or marked and final diagram

correct

1 = Correct lines moved or marked and no final

diagram drawn Or

Correct lines moved or marked but final diagram

incorrect Or

No lines moved or marked and final diagram

correct

0 = All else including lines moved or marked

incorrectly but final diagram correct

12. Memory: Total possible points are 2.

12. Memory: Total possible points are 2.

Forms 1 and 2:

2 = Exact wording only, nothing extra: “I am done”

1 = Must contain the word “done”: “Yes, I am done”,

“done”, others

0 = All else

Total points = 0 (minimum) – 22 (maximum)

_________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

**Explanation of SAGE Scoring**Please see the table below.