In the past 6–12 months, how often has your loved one repeated the same question within a short time? *

Never

Occasionally (once or twice a month)

Frequently (weekly)

Daily/Almost every day

Do they often forget familiar names, places, or events? *

No

Sometimes

Often

Almost always

Have they become disoriented in familiar places (e.g., their own neighbourhood, the supermarket they’ve used for years)? *

Never

Rarely

Occasionally

Frequently

Do they lose track of time, dates, or appointments? *

Never

Rarely

Occasionally

Frequently

Have you noticed sudden or unexplained mood changes (e.g., irritability, withdrawal, anxiety)?

Never

Rarely

Occasionally

Frequently

Have they lost interest in hobbies or activities they used to enjoy?

No

Slightly Less

Much Less

Stopped completely

Are they struggling with familiar tasks (e.g., cooking a regular meal, managing finances, using appliances)?

No

Slight difficulty

Moderate difficulty

Can not do without help

Do they misplace items and are unable to retrace their steps to find them?.

Never

Occasionally

Often

Almost Daily

Have you noticed changes in their walking, balance, or coordination?

No

Mild changes

Moderate changes

Significant changes

Have they been having trouble finding the right words or following conversations?

No

Sometimes

Often

Almost always

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