Oasis Medical Group|Dementia Screening

Dementia Screening

 

Check Yes to any of the events that have occurred within the last 6 months.  Check No if the events have not occurred in the last 6 months. Check N/A if the question does not apply to the person you are rating.

I am taking this quiz for
How many days each week do you see the person being rated?
Does the person repeat questions about the events of the day?
Does the person have trouble recalling conversations the next day?
Does the person have trouble recalling conversations a few days later?
Has there been confusion while doing familar things?
Has the person become confused about financial matters (for example, paying bills multiple times)?
Has the person become confused regarding the day, month, or year?
Has the person become lost or confused when driving or walking in a familiar place?
Has the person seemed bewildered or confused in familiar places?
Has the person become lost while traveling in an unfamiliar location?
Does the person have difficulties adjusting to changes in his/her day-to-day routine?
Does the person have trouble performing tasks that require many steps (for example, balancing checkbook or cooking small meal)?
Is the person unable to respond with a reasonable plan to problems at work or home, such as knowing what to do if the bathroom is flooded or the electricity goes out?
Are there pauses in his/her speech?
Is the person often unable to find even common words or familiar names, so that he/she finds it difficult to have a normal conversation?
Does the person often forget what he/she wanted to say in the middle of a conversation?
Have there been any changes in personality (including mood and behavior)?
Has the person been agitated?
Have the person's problems worsened steadily?
Please provide your contact information below. One of our staff members will contact you.

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