Dementia Screening Form
This form is designed to screen for signs of dementia. Please answer the following questions to the best of your ability.
Personal Information
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Medical History
Do you have a history of memory loss?
Yes
No
Have you experienced confusion or disorientation?
Yes
No
Do you have difficulty with problem-solving or planning?
Yes
No
Have you had trouble completing familiar tasks?
Yes
No
Have you experienced changes in mood or behavior?
Yes
No
Do you have difficulty with speech or writing?
Yes
No
Family History
Is there a family history of dementia?
Yes
No
Please explain if yes.
Submit
Should be Empty: