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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 that gives you the closest answers that fits the person with memory problem.

No

Early symptoms of dementia

Yes

No

Don’t know

1.

Does the person often repeats himself/ herself, or ask the same questions over and over?

 

 

 

2.

Is the person more forgetful, that is having trouble with short term memory?

 

 

 

3.

Does the person need to be reminded to do things like chores, shopping or taking medicine?

 

 

 

4.

Does the person forgets appointments, family occasions or holidays?

 

 

 

5.

Does the person seem sad, down in the dumps or cry more often than in the past?

 

 

 

6.

Has the person started having trouble doing calculations, managing finances, or balancing checkbooks?

 

 

 

7.

Has the person lost interest in his/ her usual activities such as hobbies, reading, attending church, or other social activities?

 

 

 

8.

Has the person started needing help dressing, bathing or using the bathroom?

 

 

 

9.

Has the person become more irritable, agitated or suspicious or believing things that are not real?

 

 

 

10.

Are there concerns about the person driving for example, getting lost or driving unsafely, or has the person had to stop driving?
If he/ she has never driven, answer ?No?

 

 

 

11.

Does the person have trouble finding words, finishing sentences or naming people or things?

 

 

 

 

TOTAL SCORE

 

 

 

Total number of ‘Yes’ Answer ____________

Total number of ‘Yes” answers is equal to or more than 5, there is possible dementia.

Last Reviewed : 20 April 2012
Writer : Dr. Suraya binti Yusoff
Reviewer : Dr. Lazli Bin Bakar