Early detection tool 2 Checklist for identifying people at risk for dementia 1 / 19 1.1 Forgetting events that happened recently - Memory Yes No 2 / 19 1.2 Forgetting the names of people who have just been introduced - Memory Yes No 3 / 19 1.3 Forgetting the names of family members or friends - Memory Yes No 4 / 19 1.4 Forgetting how to get home - memory Yes No 5 / 19 1.5 Forgetting where they have put important things like house keys, cell phone, or wallet/purse - Memory Yes No 6 / 19 2.1 Have difficulty finding the right words or calling things by the wrong name - Communication and language Yes No 7 / 19 2.2 Have trouble reading or writing a passage - Communication and language Yes No 8 / 19 2.3 Have a hard time following a conversation - Communication and language Yes No 9 / 19 2.4 Stopping in the middle of a conversation and unable to recall what they Stopping in the middle of a conversation and unable to recall what they were talking about Yes No 10 / 19 2.5 Repeating themselves a lot - Communication and language Yes No 11 / 19 3.1 Have difficulty completing familiar tasks, such as making a meal or keeping track of monthly bills - Attention and concentration Yes No 12 / 19 3.2 Have difficulty managing finances, particularly working with numbers - Attention and concentration Yes No 13 / 19 3.3 Taking a much longer time to do things than before - Attention and concentration Yes No 14 / 19 4.1 Have difficulty making simple decisions, such as what to wear on a cold day - Reasoning and judgement (problem solving) Yes No 15 / 19 4.2 Giving away a large amount of money to someone they just met - Reasoning and judgement (problem solving) Yes No 16 / 19 4.3 Losing track of the time, dates and season - Reasoning and judgement (problem solving) Yes No 17 / 19 5.1 Have more difficultyjudging distancesaccuratelythan before - Visual perception and spatial ability Yes No 18 / 19 5.2 Find it more difficult than before to judge directions accurately - Visual perception and spatial ability Yes No 19 / 19 5.3 Have difficulty determining color or contrast - Visual perception and spatial ability Yes No Your score is Exit
