The Clock Drawing Test: Complete Scoring and Interpretation Guide

The clock drawing test is deceptively simple: draw a clock, put in all the numbers, and set the hands to ten past eleven. It takes about three minutes. Yet a single drawing can reveal problems in executive function, working memory, and visuospatial reasoning that might take hours of testing to uncover otherwise. That's why it has been a first-line cognitive screener in primary care, geriatrics, and neurology for more than four decades.

This guide is for patients, caregivers, and clinicians who want to understand what the test actually measures, how it's scored, and how to interpret the result.

What the clock drawing test is

The clock drawing test is a screening tool — a fast way to flag possible cognitive impairment so that a more thorough evaluation can follow. It is not a diagnostic test. A score on its own cannot tell anyone whether a person has dementia, mild cognitive impairment, or delirium.

The test has been part of cognitive assessment batteries since the mid-20th century and became widely standardized after Shulman and colleagues published an early scoring framework in 1986. Versions of it now appear in national clinical guidelines, hospital protocols, and dozens of research instruments.

Clinicians like it for three reasons: it is quick, it is tolerated well by older adults who may be fatigued by longer assessments, and it is sensitive to the kinds of subtle executive-function changes that longer verbal tests sometimes miss.

What the test measures

A clock drawing task exercises several cognitive domains at once:

• Executive function — the ability to plan and sequence the task (I need a circle, then numbers, then hands, in that order)
• Semantic memory — recalling what a clock looks like
• Working memory — holding the instructed time in mind while drawing
• Visuospatial construction — arranging the numbers symmetrically around the circle
• Motor planning — translating intention into pen movement
• Abstraction — converting "ten past eleven" into a position on the clock face

That last step is where many early cases stumble. A common error is to place the minute hand on the "10" rather than on the "2," even though "ten past eleven" means ten minutes — a classic sign that abstract reasoning is affected.

How the test is administered

The standard administration looks like this:

1. The examiner provides a blank sheet of paper and a pen. (Pen rather than pencil — erasures can hide diagnostic information.)
2. The examiner says: "Please draw a clock. Put in all the numbers, and set the time to ten past eleven."
3. The patient has a few minutes, without time pressure, to complete the drawing.
4. The examiner does not repeat, rephrase, or clarify the instructions unless specifically asked.

Some versions pre-draw a circle on the page so the drawing focuses on numbers and hands only. Both variants are valid, but scores between them are not directly comparable.

Cultural and educational factors matter. Someone who grew up reading digital clocks exclusively, or who has limited formal education, may draw a less refined clock for reasons unrelated to cognition. Any scoring system should be interpreted in that context.

Scoring systems, explained

No single scoring system is universal. Different scales emphasize different aspects of the drawing, and clinicians choose based on setting and purpose. Here are the four most widely used.

Shulman scoring (0–5)

The Shulman system is probably the most common in busy clinical settings because it is fast. A clinician looks at the drawing and assigns one of six scores:

• 5 — Perfect clock.
• 4 — Minor visuospatial errors (e.g., slightly uneven spacing).
• 3 — Inaccurate representation of 10-past-11, but other elements intact.
• 2 — Moderate visuospatial disorganization (numbers crowded, missing, or duplicated).
• 1 — Severe disorganization (drawing is no longer recognizable as a clock).
• 0 — No reasonable attempt.

In clinical practice, a score of 3 or below is often used as a flag for further evaluation, though published cutoffs vary across studies and settings.

Mendez scoring (0–20)

The Mendez system is more granular. It awards points across 20 items covering three domains:

• The clock face itself (does it have a reasonable circle, appropriate size)
• The numbers (all present, in the right positions, not crowded, no duplicates)
• The hands (two hands, proportional lengths, pointing to the correct positions)

Higher scores are better. It takes longer to score but captures finer-grained errors, which is why it is often used in research or in specialist clinics doing detailed assessments.

Rouleau scoring (0–10)

The Rouleau system, developed to distinguish Alzheimer's from Huntington's disease, combines a 10-point quantitative score with a qualitative analysis of error types. It separates:

• Graphic errors — poor drawing quality
• Stimulus-bound errors — misreading "10 past 11" as "put the hand on 10"
• Conceptual deficits — drawing something that is no longer clock-like
• Spatial or planning deficits — crowding numbers on one side of the clock
• Perseveration — repeating numbers or adding extra strokes

The Rouleau framework is especially useful when clinicians want to think about what kind of cognitive problem the drawing suggests, not just how severe.

Royall CLOX (CLOX-1 and CLOX-2)

The CLOX system is different from the others. It splits the task into two parts:

• CLOX-1 — The patient draws a clock from memory with the standard instruction. This measures executive function (planning from scratch).
• CLOX-2 — The patient copies a pre-drawn clock. This measures construction (pure visuospatial ability).

A low CLOX-1 with a relatively preserved CLOX-2 suggests executive dysfunction — a pattern common in frontal and subcortical dementias. A low CLOX-2 points more toward visuospatial deficits associated with Alzheimer's disease or posterior cortical atrophy.

CLOX is scored out of 15 points for each part, with published cutoffs that have been refined across populations in follow-up studies.

How to interpret a result

A clock drawing test result is one data point, not a diagnosis.

A low score means "worth investigating"

Across scoring systems, a clearly below-average score is a reasonable trigger for further evaluation — typically a full history, physical exam, blood work to rule out treatable causes (thyroid, B12, vitamin D, medication effects), and a longer cognitive assessment such as the MoCA. In some cases, imaging follows.

A perfect score is reassuring but not proof

The clock drawing test is not fully sensitive to the earliest stages of cognitive impairment. A person with early mild cognitive impairment can draw a perfectly normal clock. If functional concerns persist — difficulty with familiar tasks, personality changes, repeated questions — a perfect clock should not end the conversation.

Sensitivity and specificity

Published sensitivity and specificity figures vary widely across scoring systems and populations. What is consistent across studies: the clock drawing test performs best as a screen when paired with another instrument — for example, the Mini-Cog, which adds a three-item recall task to a clock drawing.

Limitations to understand

A responsible reading of a clock drawing test always accounts for:

• Education level. Higher-educated patients may compensate well into moderate dementia; less-educated patients can score lower for reasons unrelated to cognition.
• Visual and motor impairment. Poor vision, tremor, or arthritis can produce a messy clock that has nothing to do with cognition.
• Language and cultural context. The abstract concept of "ten past eleven" assumes familiarity with analog clocks, which varies.
• Acute conditions. Delirium, dehydration, infection (especially urinary tract infections in older adults), medication side effects, and severe depression can all cause temporary impairment.
• Testing context. A stressful or rushed exam room produces different drawings than a quiet kitchen table.

None of these invalidate the test. They just mean a score should be read alongside the whole clinical picture.

What to do after a low score

If you or a loved one has scored low on a clock drawing test:

1. Don't assume a diagnosis. A screening result is not a diagnosis.
2. Make a medical appointment. Start with your primary care physician. Bring a family member if possible — they can describe changes the patient may not notice.
3. Bring a medication list. Some medications (anticholinergics, sedatives, opioids) commonly used in older adults can cause cognitive effects that mimic dementia.
4. Expect a broader evaluation. Your doctor will likely take a detailed history, order blood work, and possibly administer a longer cognitive test or refer to a specialist.
5. Don't wait. Many of the causes of a low score — depression, medication effects, thyroid dysfunction, B12 deficiency, sleep apnea — are treatable. Early evaluation is how you find out which.

For a longer walk-through of next steps, see our guide to what to do after a low clock drawing test score.

Frequently asked questions

Can I take the clock drawing test at home?

Yes. The test is in the public domain and can be self- or family-administered. Tokei Health offers a free online version that uses the standard instruction and a clean drawing surface. For guidance on administering it in person at home, see our caregiver how-to guide.

Is a clock drawing test enough to diagnose dementia?

No. The clock drawing test is a screening tool. A dementia diagnosis requires a comprehensive evaluation including medical history, cognitive testing, ruling out reversible causes, and often neuroimaging.

How often can the test be repeated?

It can be repeated as often as clinically indicated, but same-day repeats have limited value (practice effects). Most clinicians use it to establish a baseline and then compare every six to twelve months, or when there is a change in function.

Can anxiety or depression affect the result?

Yes. Depression in older adults can produce cognitive patterns that resemble early dementia — sometimes called "pseudodementia." A low score in a depressed patient should be reassessed after depression is treated.

Is the test valid across cultures?

The test has been adapted and validated in many languages and cultures, though not universally. For populations where analog clocks are less familiar, clinicians weigh the result more cautiously.

What's a normal score by age?

There is no single age-adjusted normative score that applies across all scoring systems. Most published norms suggest that healthy adults across a wide age range should score at or near the top of whichever scale is used, provided they have reasonable vision and education. Significant deviation from that is worth investigating, regardless of age.

Related reading

• Early Signs of Dementia vs Normal Aging: A Guide for Families
• MMSE vs Clock Drawing Test vs MoCA: Which Cognitive Screening Should You Take?
• What to Do After a Low Clock Drawing Test Score
• Clock Drawing Test for Caregivers: How to Administer at Home

References

• Shulman KI, Shedletsky R, Silver IL. The challenge of time: Clock-drawing and cognitive function in the elderly. International Journal of Geriatric Psychiatry. 1986;1(2):135–140.
• Mendez MF, Ala T, Underwood KL. Development of scoring criteria for the clock drawing task in Alzheimer's disease. Journal of the American Geriatrics Society. 1992;40(11):1095–1099.
• Rouleau I, Salmon DP, Butters N, Kennedy C, McGuire K. Quantitative and qualitative analyses of clock drawings in Alzheimer's and Huntington's disease. Brain and Cognition. 1992;18(1):70–87.
• Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. Journal of Neurology, Neurosurgery, and Psychiatry. 1998;64(5):588–594.

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Disclosure: Dr. Shimada is the founder of Tokei Health. This article is informational and is not a substitute for individual medical advice from your own clinician.