10 Early Warning Signs of Dementia
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Email address
First name
Informant name *
Location *
0 = Doesn't apply,   1 = Mild,   2 = Moderate,   3 = Severe
Please mark 0 unless the behaviour has been PRESENT for at least 6 months (continuously or on-and-off)
and is CHANGE from her/his longstanding pattern of behaviour.

Please rate severity:
1 = Mild (noticeable, but not a significant change);
2 = Moderate (significant, but not a dramatic change);
3 = Severe (very marked or prominent, a dramatic change). If more than 1 item in a question, rate the most severe.

1. Has the person lost memory of recent events or new information? *
Doesn't apply
Severe
2. Does the person repeat themselves, or repeat behaviours, more frequently? *
Doesn't apply
Severe
3. Does the person have more difficulty doing familiar, but difficult tasks (e.g. managing money, medications, driving etc)? *
Doesn't apply
Severe
4. Does the person have increased difficulty with language (e.g. finding words or names, or misunderstanding others)? *
Doesn't apply
Severe
5. Is the person becoming more confused about time or place (e.g. getting lost while driving or missing appointments)? *
Doesn't apply
Severe
6. Is the person's judgement getting worse? Are they having difficulty thinking things through like before? *
Doesn't apply
Severe
7. Is the person having reasoning difficulties (e.g. difficulty solving problems, or with abstract thinking)? *
Doesn't apply
Severe
8. Is the person increasingly misplacing things, or putting things in odd places? *
Doesn't apply
Severe
9. Has their personality changed? Are they sad, have mood swings, suspicious? Are they more dis-inhibited, outgoing? *
Doesn't apply
Severe
10. Has the person lost initiative? Have they isolated themselves and withdrawn from normal activities and interests? *
Doesn't apply
Severe
Copyright Bruce Thompson © 2019
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