Has his/her memory worsened in the past few years?

A. No
B. Yes

Does he/she frequently forget appointments and important events?

A. No
B. Yes

Does he/she many times misplace personal items like keys, wallet, purse, etc?

A. No
B. Yes

Does he/she have trouble remembering to take medications, or keeping track of medication schedules?

A. No
B. Yes

Does he/she have recently started having difficulty in driving, or are you worried about their driving skills?

A. No
B. Yes

Does he/she talk about the same thing or event or story several times a day?

A. No
B. Yes

Does new or unfamiliar places makes him/her confused or disoriented?

A. No
B. Yes

Is he/she behaving in a disoriented way in familier environment as well?

A. No
B. Yes

Did he/she lost interest in any kind of hobbies, games, crafts, or physical exercise?

A. No
B. Yes

Can he/she show difficulty or confusion while using/operating familier appliances like microwave, dishwasher, washer, etc?

A. No
B. Yes

Does he/she frequently forgets correct month or year? *

A. No
B. Yes

Can he/she has difficulty paying bills & managing even small personal finances?

A. No
B. Yes

Can he/she show difficulty or confusion while finding words while speaking, other than names?

A. No
B. Yes

Does he/she confuse about the names of family members?

A. No
B. Yes

Can he/she display trouble in recognizing familiar people?

A. No
B. Yes