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

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

2. Do you frequently forget appointments and important events?

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

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

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

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

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

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

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

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

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

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

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

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

15. Do you have trouble recognizing familiar people?

16. Are you currently caring for someone?