Cognitive Health Test

This is a three-part test that involves reading and speaking. Please complete all three parts of the assessment to get the results.

Part 1: Alzheimer's/Dementia/Memory Loss Checklist

1. Has your memory worsened in the past few years?

Yes No

2. Do you frequently forget appointments and important events?

Yes No

3. Do you frequently misplace personal items, such as keys, wallet, or purse?

Yes No

4. Do you have trouble remembering to take medications or keeping track of medication schedules?

Yes No

5. Do you have difficulty driving, or are you concerned about your driving ability?

Yes No

6. Do you ask the same question or repeat the same thing (or story) several times in the same day?

Yes No

7. Do you become confused or disoriented in new, unfamiliar places?

Yes No

8. Are you getting lost or disoriented in familiar places and settings?

Yes No

9. Have you lost interest in hobbies, games, crafts, or exercise? (excluding physical limitations)

Yes No

10. Do you have difficulty or confusion with operating familiar appliances, such as a microwave or dishwasher?

Yes No

11. Do you frequently not know the correct month or year?

Yes No

12. Do you have difficulty paying bills and managing personal finances?

Yes No

13. Do you frequently have trouble finding words, other than names?

Yes No

14. Do you confuse the names of family members or close friends?

Yes No

15. Do you have trouble recognizing familiar people?

Yes No

16. Are you currently caring for someone?

Yes No

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