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Mental Disease for Golden Years

Symptom Of Dementia Screener

Memory Problem Checklist (Answered by caregiver) Name of Caregiver :_____________________________ Date:______________________ Name of patient______________________________________ Sex : Male/Female Your relationship (caregiver) with patient: Partner/Adult child/Grandchildren/Friends/Other(specify):___________________ Answer the questions below to help decide whether the memory problems of the person you are looking after has early signs of dementia. See the box …

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