Are the memory problems of the person you care for, symptoms of Alzheimer’s disease.


Answer the questions below to help find out if the memory problems of the person you care for could be symptoms of Alzheimer's disease.

Your answers do not mean the person you have answered for has a disease such as Alzheimer's.  But 5 or more "Yes" answers suggest memory problems that may interfere with daily life.  You should see the doctor.

Does the person you care for:

1.         Often repeat himself/herself or ask            □ Yes   □ No  □ Don't know

            the same questions over and over?

2.         Seem more forgetful, that is, have              □ Yes   □ No  □ Don't know

            trouble with short-term memory?

3.         Need reminders to do things like                □ Yes   □ No   □ Don't know

            chores, shopping, or taking medicine?

4.         Forget appointments, family occasions,    □ Yes   □ No   □ Don't know

            or holidays?

5.         Seem sad, down in the dumps, or cry      □ Yes    □ No   □ Don't know

            more than in the past?

6.         Have trouble doing calculations,              □ Yes    □ No   □ Don't know

            managing finances, or balancing the


7.         Seem to have lost interest in his/her        □ Yes    □ No   □ Don't know

            activities such as hobbies, reading,

            attending a religious service?

8.         Need help eating, dressing, bathing,       □ Yes    □ No   □ Don't know

            or using the bathroom?

9.         Seem irritable, agitated, suspicious, or    □ Yes    □ No   □ Don't know

            started seeing, hearing, or believing

            things that are not real?

10.       Get lost driving or drive unsafely, or         □ Yes      □ No   □ Don't know

            has the person had to stop driving?

11.       Have trouble finding the words he/she      □ Yes     □ No   □ Don't know

            wants to say, finishing sentences,

            or naming people or things?

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