Alzheimer's/Dementia/Memory Loss Checklist

Has his/her memory worsened in the past few years? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she frequently forget appointments and important events? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she frequently misplace personal items? (keys, wallet, purse, etc.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she have trouble remembering to take medications, or keeping track of medication schedules? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she have difficulty driving, or are you concerned about their driving ability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she ask the same question, or repeat the same thing (or story) several times in the same day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she become confused or disoriented in *new*, unfamiliar places? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is he/she getting lost or disoriented in *familiar* places and settings? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Has he/she lost interest in hobbies,games,crafts, or exercise? (excluding physical limitations) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she have difficulty or confusion with operating familiar appliances? (microwave, dishwasher, etc) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she frequently not know the correct month or year? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she have difficulty paying bills & managing personal finances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she frequently have trouble finding words, other than names? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she confuse the names of family members or close friends? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she have trouble recognizing familiar people? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently caring for someone? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email - to receive your report {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Calc {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }