Alzheimer's/Dementia/Memory Loss Checklist
Has his/her memory worsened in the past few years?
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Does he/she frequently forget appointments and important events?
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Does he/she frequently misplace personal items? (keys, wallet, purse, etc.)
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Does he/she have trouble remembering to take medications, or keeping track of medication schedules?
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Does he/she have difficulty driving, or are you concerned about their driving ability?
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Does he/she ask the same question, or repeat the same thing (or story) several times in the same day?
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Does he/she become confused or disoriented in *new*, unfamiliar places?
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Is he/she getting lost or disoriented in *familiar* places and settings?
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Has he/she lost interest in hobbies,games,crafts, or exercise? (excluding physical limitations)
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Does he/she have difficulty or confusion with operating familiar appliances? (microwave, dishwasher, etc)
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Does he/she frequently not know the correct month or year?
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Does he/she have difficulty paying bills & managing personal finances?
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Does he/she frequently have trouble finding words, other than names?
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Does he/she confuse the names of family members or close friends?
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Does he/she have trouble recognizing familiar people?
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Email - to receive your report
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Calc
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Back
Submit
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Alzheimer's/Dementia/Memory Loss Checklist
Has his/her memory worsened in the past few years?
{binding displayValue}
Does he/she frequently forget appointments and important events?
{binding displayValue}
Does he/she frequently misplace personal items? (keys, wallet, purse, etc.)
{binding displayValue}
Does he/she have trouble remembering to take medications, or keeping track of medication schedules?
{binding displayValue}
Does he/she have difficulty driving, or are you concerned about their driving ability?
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Does he/she ask the same question, or repeat the same thing (or story) several times in the same day?
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Does he/she become confused or disoriented in *new*, unfamiliar places?
{binding displayValue}
Is he/she getting lost or disoriented in *familiar* places and settings?
{binding displayValue}
Has he/she lost interest in hobbies,games,crafts, or exercise? (excluding physical limitations)
{binding displayValue}
Does he/she have difficulty or confusion with operating familiar appliances? (microwave, dishwasher, etc)
{binding displayValue}
Does he/she frequently not know the correct month or year?
{binding displayValue}
Does he/she have difficulty paying bills & managing personal finances?
{binding displayValue}
Does he/she frequently have trouble finding words, other than names?
{binding displayValue}
Does he/she confuse the names of family members or close friends?
{binding displayValue}
Does he/she have trouble recognizing familiar people?
{binding displayValue}
Email - to receive your report
{binding displayValue}
Calc
Alzheimer's/Dementia/Memory Loss Checklist
Has his/her memory worsened in the past few years?
{binding displayValue}
Does he/she frequently forget appointments and important events?
{binding displayValue}
Does he/she frequently misplace personal items? (keys, wallet, purse, etc.)
{binding displayValue}
Does he/she have trouble remembering to take medications, or keeping track of medication schedules?
{binding displayValue}
Does he/she have difficulty driving, or are you concerned about their driving ability?
{binding displayValue}
Does he/she ask the same question, or repeat the same thing (or story) several times in the same day?
{binding displayValue}
Does he/she become confused or disoriented in *new*, unfamiliar places?
{binding displayValue}
Is he/she getting lost or disoriented in *familiar* places and settings?
{binding displayValue}
Has he/she lost interest in hobbies,games,crafts, or exercise? (excluding physical limitations)
{binding displayValue}
Does he/she have difficulty or confusion with operating familiar appliances? (microwave, dishwasher, etc)
{binding displayValue}
Does he/she frequently not know the correct month or year?
{binding displayValue}
Does he/she have difficulty paying bills & managing personal finances?
{binding displayValue}
Does he/she frequently have trouble finding words, other than names?
{binding displayValue}
Does he/she confuse the names of family members or close friends?
{binding displayValue}
Does he/she have trouble recognizing familiar people?
{binding displayValue}
Email - to receive your report
{binding displayValue}
Calc