Do You Have Alzheimer’s? Ask a Loved One to Answer this Questionnaire

Find out your risk of having Alzheimer’s disease using this 21-item questionnaire. While this is not a definitive way to diagnose Alzheimer’s, this can help you assess your situation and see if further steps must be taken. It’s still best to consult with your doctor for the right diagnosis and treatment.

Alzheimer’s Questionnaire

Answer Yes or No to the following questions.

Memory

1. Does your loved one have memory loss?

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

Orientation

7. 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)

 Yes  No

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

 Yes  No

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

 Yes  No

Functional Ability (excluding physical limitations)

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

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

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

 Yes  No

Visuospatial Ability

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

 Yes  No

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

 Yes  No

Language

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

 Yes  No

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

 Yes  No

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

 Yes  No

How to interpret your 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

Source: www.helpguide.org

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If you or your loved one has already been diagnosed with Alzheimer’s or are still about to have a consultation, Big Hearts is still here to help take care of your loved one. Call or text us at 09565012540 to know your options.