This questionnaire will determine if your loved one may have some form of dementia. You must answer all eleven questions. Your answers do not mean the person has Alzheimer’s disease, but that a doctor’s visit is needed for the proper diagnosis. The results of this questionnaire should be shared with the MD.
1. Does the person often repeat him or herself or ask the same questions over and over?
Yes No Don’t know
2. Is the person more forgetful or having problems with short-term memory?
Yes No Don’t know
3. Does the person need reminders to do things like chores, shopping or taking medications?
Yes No Don’t know
4. Does the person forget appointments, family occasions, or holidays?
Yes No Don’t know
5. Does he/she seem sad, down in the dumps, or cry more often than in the past?
Yes No Don’t know
6. Is the person having problems doing calculations, managing finances, or balancing the checkbook?
Yes No Don’t know
7. Has he/she lost interest in his/her activities such as hobbies, reading, attending church or other social activities?
Yes No Don’t know
8. Has the person started needing help eating, dressing, bathing, or using the bathroom?
Yes No Don’t know
9. Has he/she become irritable, agitated, suspicious, or started seeing, hearing or believing things that are not real?
Yes No Don’t know
10. Are there concerns about his/her driving? For example getting lost or driving unsafely, or has had to stop driving? If the person has never driven, answer “no”.
Yes No Don’t know
11. Does the person have trouble finding the words he/she wants to say, finishing sentences, or naming people or things?
Yes No Don’t know
Totals: Yes No Don’t know
Be sure to take this test and a list of questions with you when you take the client to the doctor’s office. The test may help the doctor make a diagnosis. In addition to this test, the doctor will ask for a complete medical history. The doctor will usually do a physical examination and lab tests. The MD may order an MRI (magnetic resonance imaging), a CT (computerized tomography) scan or additional memory tests. Ask the questions that matter the most to you first. Be open and honest. Don’t be afraid to ask for clearer answers from the doctor, when necessary. The doctor may order new medications for the client.
Computer Link for Test:
http://www.alzheimersconcern.com/memory1.php