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Memory Loss Questionnaire

· Mind

Use this questionnaire to test whether a person's memory loss needs further assessment.

Memory

Yes

No

  1. Does your loved one have memory loss?

 

 

  1. If yes,is his or her memory worse than a few years ago?

 

 

  1. Does your loved one repeat questions, statements, or stories in the same day?(2 points)

 

 

  1. Have you had to take over tracking events or appointments,or does your loved one forget appointments?

 

 

  1. Does your loved one misplace items more than once per month, or so that he or she can't find them?

 

 

  1. Does your loved one suspect others of hiding or stealing items when he or she cannot find them?

 

 

Orientation

 

 

  1. 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)

 

 

  1. Does your loved one become disoriented in unfamiliar places?

 

 

  1. Does your loved one become more confused outside the home or when traveling?

 

 

Functional Ability (excluding physical limitations)

 

 

  1. Does your loved one have trouble handling money (tips, calculating change)?

 

 

  1. Does your loved one have trouble paying bills or doing finances? (2 points)

 

 

  1. Does your loved one have trouble remembering to take medicines or tracking medications taken?

 

 

  1. Does your loved one have difficulty driving or are you concerned about him or her driving?

 

 

  1. Is your loved one having trouble using appliances (e.g. microwave, oven, stove, remote control, telephone, alarm clock)?

 

 

  1. Does your loved one have difficulty completing home repair or other home-related tasks, such as housekeeping?

 

 

  1. Has your loved one given up or significantly cut back on hobbies such as golf, dancing, exercise, or crafts?

 

 

Visuospatial Ability

 

 

  1. Does your loved one get lost in familiar surroundings, such as their own neighborhood? (2 points)

 

 

  1. Does he or she have a decreased sense of direction?

 

 

Language

 

 

  1. Does your loved one have trouble finding words other than names

 

 

  1. Does your loved one confuse names of family members or friends? (2 points)

 

 

  1. Does your loved one have trouble recognizing familiar people? (2 points)

 

 

Score:

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

This post is for informational purposes only. It should not be considered therapy. This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental Health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393.

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This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393.