Full Name *

Date

Phone *

Email *

Caregiver *

Length of Caregiving *

1a. Fails to recognize friends *

1b. Fails to recognize friends *

2a. Fails to recognize family *

2b. Fails to recognize family *

3a. Forgets year *

3b. Forgets year *

4a. Forgets month *

4b. Forgets month *

5a. Forgets day of week *

5b. Forgets day of week *

6a. Unable to name place (town, etc.) *

6b. Unable to name place (town, etc.) *

7a. Fails to recognize familiar places *

7b. Fails to recognize familiar places *

8a. Gets lost in neighborhood (walking) *

8b. Gets lost in neighborhood (walking) *

9a. Gets lost driving *

9b. Gets lost driving *

10a. Gets lost in own home *

10b. Gets lost in own home *

11a. More confused at night *

11b. More confused at night *

12a. More confused in new places *

12b. More confused in new places *

13a. Wanders and gets lost *

13b. Wanders and gets lost *

14a. Loses/misplaces small items *

14b. Loses/misplaces small items *

15a. Loses/misplaces valuable things *

15b. Loses/misplaces valuable things *

16a. Forgets to pay bills *

16b. Forgets to pay bills *

17a. Forgets to eat *

17b. Forgets to eat *

18a. Unable to recall what was read *

18b. Unable to recall what was read *

19a. Forgets to turn things off *

19b. Forgets to turn things off *

20a. Forgets what conversation is about *

20b. Forgets what conversation is about *

21a. Unable to follow what’s on TV *

21b. Unable to follow what’s on TV *

22a. Forgets to bathe *

22b. Forgets to bathe *

23a. Forgets major events of the day *

23b. Forgets major events of the day *

24a. Forgets major events of the week *

24b. Forgets major events of the week *

25a. Forgets major events from distant past *

25b. Forgets major events from distant past *

26a. Unable to initiate conversation *

26b. Unable to initiate conversation *

27a. Misunderstands what others say *

27b. Misunderstands what others say *

28a. Unable to respond to questions *

28b. Unable to respond to questions *

29a. Has trouble finding right words *

29b. Has trouble finding right words *

30a. Just speaks in phrases *

30b. Just speaks in phrases *

31a. Avoids questions *

31b. Avoids questions *

32a. Unable to verbalize needs *

32b. Unable to verbalize needs *

34a. What is said makes little sense *

34b. What is said makes little sense *

35a. Walks short, shuffling gait *

35b. Walks short, shuffling gait *

36a. Gait slow and labored *

36b. Gait slow and labored *

37a. Tires easily when walking *

37b. Tires easily when walking *

38a. Unable to get up from chair alone *

38b. Unable to get up from chair alone *

39a. Unable to use stairs *

39b. Unable to use stairs *

40a. Unable to use eating utensils *

40b. Unable to use eating utensils *

41a. Unable to write name *

41b. Unable to write name *

42a. Hands/arms shake *

42b. Hands/arms shake *

43a. Has problems sleeping *

43b. Has problems sleeping *

44a. Has toileting accidents *

44b. Has toileting accidents *

45a. Talks excessively about past *

45b. Talks excessively about past *

46a. Denies problems *

46b. Denies problems *

47a. Gets upset easily *

47b. Gets upset easily *

48a. Becomes physically violent *

48b. Becomes physically violent *

49a. Shows poor judgment *

49b. Shows poor judgment *

50a. Has trouble taking medication *

50b. Has trouble taking medication *

51a. Drives unsafely *

51b. Drives unsafely *

52a. Very withdrawn, refuses to leave house *

52b. Very withdrawn, refuses to leave house *

53a. Very nervous and restless *

53b. Very nervous and restless *

54a. Walks and paces constantly *

54b. Walks and paces constantly *

55a. Very suspicious/paranoid *

55b. Very suspicious/paranoid *

56a. Has delusional ideas *

56b. Has delusional ideas *

57a. Has hallucinations *

57b. Has hallucinations *

58a. Sexually inappropriate *

58b. Sexually inappropriate *