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Hahnemann Orientation and Memory Examination (HOME)J. Michael Williams & Sandra KofflerName: ______________________________Date: __________Date of Injury: __________________Age: _________ Education:______________Occupation: ___________________________________Instructions: Ask the patient each of the following questions. If the patient cannot respond, orresponds incorrectly, then suggest three multiple choice alternatives. Circle point values on the rightwhich correspond to the patient's performance. Sum these point values for each major section. TheGOAT summary score is computed by subtracting the total "GOAT Fail" error points from 100.Memory Screen (24hrs)1-23-45-67-89-15Very ImpairedImpairedNormal LimitsPersonal OrientationPlace OrientationTime OrientationAnterograde AmnesiaGOAT0-56-110-50-60-50-336-117-136-1134-6512-1718-2012-1718-2314-1718-2312-1718-2366-7071-7521-222424-322476-100Memory Screen (Imm)1-34-56-89-1011-15Duration of Retrograde Amnesia: Duration of Anterograde Amnesia:ILLNESS Mult Choice PassPassFailGOAT Fail PointsPersonal Orientation:1. What is your name? _________________________________________________________________________________2. What is your age?_________________________________________________________________________________3. Where were you born?_________________________________________________________________________________4. What is your date of birth?_________________________________________________________________________________5. What is your address?_________________________________________________________________________________6. What is your telephone number?_________________________________________________________________________________7. Are you married?_________________________________________________________________________________8. What is your occupation?_____________________________________________________________________210221042021044204420210210Orientation to Place:9. What state are we in? _________________________________________________________________________________10. What city (town) are we in? _________________________________________________________________________________11. Where are you right now? _________________________________________________________________________________12. What is the name of this hospital? _____________________________________________________________________Personal Orientation Subtotal: 42063056305840Place Orientation Subtotal: