HomeAltheimer's Screening

Altheimer's Screening

 
 
 
 
 
 
 
 
Where does your family member live?
 
 

Family Member Questionnaire for possible dementia

 
1. Does your family member repeat questions about things that occurred during the day?
 
 
2. Does your family member forget that they had specific conversations by the next day?
 
 
3. Have you noticed your family member to be confused while doing familiar things?
 
 
4. Have you noticed that your family members forgets conversations from a few days ago?
 
 
5. Have you noticed a gradual but steady decline?
 
 
6. Has the family member’s problems worsened steadily?
 
 
7. Has your family member seemed agitated?
 
 
8. Does your family member frequently forget what s/he wanted to say while speaking?
 
 
9. Have you noticed changes in your family members mood or behavior?
 
 
10. Have you noticed that you family member becomes lost or disoriented while traveling to familiar location?
 
 
11. Have you noticed that your family member becomes bewildered or confused in unfamiliar places?
 
 
12. Does your family member seem confused, at times, about the day, month or year?
 
 
13. Does your family member seem unable to develop a reasonable plan to handle daily problems at home or work?
 
 
14. Does your family member have difficulty when their daily routine is altered?
 
 
15. Does your family member seem to pause for no apparent reason when speaking?
 
 
16? Does your family member have trouble remembering the names of common places, people or things?
 
 
17. Does your family member seem to think slower than they use to?
 
 
18. Does your family member have good recall of events from long ago, but, forget things that have recently occurred?
 
 
19. Does your family member have trouble doing daily tasks that require following written directions such as hooking up a new DVD player or TV?
 
 
20. Does your family member have difficulty performing tasks that require a lot of steps, such as reconciling the checkbook?
 
 
 
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