Use this questionnaire to test whether a person's memory loss needs further assessment.
- Does your loved one have memory loss?
- If yes,is his or her memory worse than a few years ago?
- Does your loved one repeat questions, statements, or stories in the same day?(2 points)
- Have you had to take over tracking events or appointments,or does your loved one forget appointments?
- Does your loved one misplace items more than once per month, or so that he or she can't find them?
- Does your loved one suspect others of hiding or stealing items when he or she cannot find them?
- Does your loved one frequently have trouble knowing the day, date, month, year, or time, or check the date more than once a day? (2 points)
- Does your loved one become disoriented in unfamiliar places?
- Does your loved one become more confused outside the home or when traveling?
Functional Ability (excluding physical limitations)
- Does your loved one have trouble handling money (tips, calculating change)?
- Does your loved one have trouble paying bills or doing finances? (2 points)
- Does your loved one have trouble remembering to take medicines or tracking medications taken?
- Does your loved one have difficulty driving or are you concerned about him or her driving?
- Is your loved one having trouble using appliances (e.g. microwave, oven, stove, remote control, telephone, alarm clock)?
- Does your loved one have difficulty completing home repair or other home-related tasks, such as housekeeping?
- Has your loved one given up or significantly cut back on hobbies such as golf, dancing, exercise, or crafts?
- Does your loved one get lost in familiar surroundings, such as their own neighborhood? (2 points)
- Does he or she have a decreased sense of direction?
- Does your loved one have trouble finding words other than names
- Does your loved one confuse names of family members or friends? (2 points)
- Does your loved one have trouble recognizing familiar people? (2 points)
Interpreting the score:
- 0 to 4: No cause for concern
- 5 to 14: Memory loss may be MCI, an early warning of Alzheimer's
- 15 and above: Alzheimer's may have already developed
This questionnaire is not intended to replace professional diagnosis.
Source: BMC Geriatrics
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