Alzheimer’s Assessment

Does your loved one have memory loss?*

Yes

No

If so, is their memory worse than a few years ago?*

Yes

No

Do they repeat statements or stories in the same day?*

Yes

No

Have you had to take over tracking events or appointments, or does the patient forget appointments?*

Yes

No

Do they misplace items more than once a month?*

Yes

No

Do they suspect others of hiding, or stealing items when they cannot find them?*

Yes

No

Does your loved one frequently have trouble knowing the day, date, month, year, and time; or check the date more than once a day?*

Yes

No

Do they become disoriented in unfamiliar places?*

Yes

No

Do they become more confused when not at home or when traveling?*

Yes

No

Excluding physical limitations, do they have trouble handling money, such as tips or calculating change?*

Yes

No

Do they trouble paying bills or doing finances?*

Yes

No

Does your loved one have trouble remembering to take medicines or keeping track of medications taken?*

Yes

No

Do they difficulty driving; or are you concerned about their driving?*

Yes

No

Are they having trouble using appliances, such as the stove, phone, remote control, microwave?*

Yes

No

Excluding physical limitations, are they having difficulty completing home repair or housekeeping tasks?*

Yes

No

Excluding physical limitations, have they given up or cut down on hobbies such as golf, dancing, exercise or crafts?*

Yes

No

Are they getting lost in familiar surroundings, such as their own neighbourhood?*

Yes

No

Is their sense of direction failing?*

Yes

No

Do they have trouble finding words other than names?*

Yes

No

Do they confuse names of family members or friends?*

Yes

No

Do they have trouble recognizing familiar people?*

Yes

No

Alzheimer’s Assessment

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