Over the past two weeks, how often did your loved one have problems with: |
Cognitive items |
1 Judgment or decision-making
2 Repeating the same things over and over, such as questions or stories
3 Forgetting the correct month or year
4 Handling complicated financial affairs, such as balancing checkbook, income taxes, and paying bills
5 Remembering appointments
6 Thinking or memory
|
Functional items |
7 Learning how to use a tool, appliance, or gadget
8 Planning, preparing, or serving meals
9 Taking medications in the right dose at the right time
10 Walking or physical ambulation
11 Bathing
12 Shopping for personal items like groceries
13 Housework or household chores
14 Leaving her/him alone
15 Her/his safety
16 Her/his quality of life
17 Falling or tripping
|
Behavioral and psychological items |
18 Less interest or pleasure in doing things, hobbies, or activities
19 Feeling down, depressed, or hopeless
20 Being stubborn, agitated, aggressive, or resistive to help from others
21 Feeling anxious, nervous, tense, fearful or panic
22 Believing others are stealing from them or planning to harm them
23 Hearing voices, seeing things, or talking to people who are not there
24 Poor appetite or overeating
25 Falling asleep, staying asleep, or sleeping too much
26 Acting impulsively, without thinking through the consequences of her/his actions
27 Wandering, pacing, or doing things repeatedly
|
Caregiver quality of life items |
Over the past two weeks, how often did you have problems with: |
28 Your quality of life
29 Your financial future
30 Your mental health
31 Your physical health
|