sage form 1 - Memory and Thinking Test Form (NZ)

Sep 30, 2026

Upload by Terk

SAGE Form 1 is a structured assessment questionnaire for evaluating memory and thinking abilities. It collects demographic details and self-reported history of problems with memory or thinking, balance issues, prior major or minor stroke, mood symptoms, personality changes, and functional difficulties in daily activities. The test includes date recall, picture naming, a short memory instruction reminder, drawing tasks involving a clock, animal naming, and line-drawing sequencing exercises with circles, numbers, letters, and triangle/square configurations. Copyright and medical disclaimer language are included.

LanguageEnglish

CategoryExam

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

Form Instructions

Background and Self-Report Questions

Cognitive Questions and Memory/Drawing Tasks

Review, Finish, and Disclaimer

How Well Are You Thinking? Please complete this form in ink without the assistance of others. | Name Date ofBirth / / How far did you get in school? I am a Man Woman I am NZ European Māori P acific Islander Asian 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):
| | | | | ©2007-2017 The Ohio State University. All Rights Reserved. D. Scharre MD, version 6.13 [http://sagetest.osu.edu](http://sagetest.osu.edu) Page 1 of 5 | 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 20 cent pieces are in $2.40?
5. You are buying $13.40 of groceries. How much change would you receive back from a $20 note? | | --- | | .
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 | ©2007-2017 The Ohio State University. All Rights Reserved. D. Scharre MD, version 6.13 [http://sagetest.osu.edu](http://sagetest.osu.edu) Page 2 of 5 | 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) . | |
End
Start | | | | 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) . | |
Start
End | | | ©2007-2017 The Ohio State University. All Rights Reserved. D. Scharre MD, version 6.13 [http://sagetest.osu.edu](http://sagetest.osu.edu) Page 3 of 5 | 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) . | | --- | | | | Put them here (at arrows)
1 triangle, 1 square Move these 2 lines Make 2 squares (answer)
(Example) (Example) (Example) | | 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) .

2 squares, 2 triangles Move 4 lines Draw answer here Mark with an X 4 squares | | 12. Have you finished? | ©2007-2017 The Ohio State University. All Rights Reserved. D. Scharre MD, version 6.13 [http://sagetest.osu.edu](http://sagetest.osu.edu) Page 4 of 5 STOP COPYRIGHT © 2007-2017 THE OHIO STATE UNIVERSITY ALL RIGHTS RESERVED Douglas W. Scharre, [Scharre.1@osu.edu](Scharre.1@osu.edu),(614) 293-4969 This instrument cannot su

FAQs

What information does SAGE Form 1 collect at the beginning?

It collects basic details such as name, date, education progress, and self-reported history about memory/thinking problems, balance problems, stroke history, mood, personality changes, and everyday activity difficulties.

What cognitive tasks are included in the test?

The form includes a date recall question, picture naming, a delayed memory instruction prompt (“I am done”), a clock drawing task with labeled long/short hands, animal naming, and line-drawing sequencing exercises.

Is SAGE Form 1 a substitute for medical diagnosis or treatment?

No. The document states the instrument cannot substitute for medical advice, diagnosis, or treatment by a trained medical professional, and includes a broad “AS IS” and liability disclaimer.

Sep 30, 2026

Upload by Terk