Caregiver Cognitive Decline Questionnaire
Please complete this questionnaire to help assess changes in cognitive function of the individual you care for. Your observations are valuable for supporting their well-being.
Caregiver's Full Name
*
First Name
Last Name
Caregiver's Email Address
*
example@example.com
Caregiver's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Person Being Assessed
*
First Name
Last Name
Relationship to the Person Being Assessed
*
Please Select
Spouse/Partner
Child
Sibling
Friend
Professional Caregiver
Other
How long have you been providing care for this person?
*
Please Select
Less than 6 months
6 months to 1 year
1-3 years
More than 3 years
Please rate the following aspects of the person's cognitive abilities compared to six months ago:
*
Rows
No Change
Slight Decline
Moderate Decline
Significant Decline
Memory (forgetting recent events, repeating questions)
1
2
3
4
Attention/Concentration
5
6
7
8
Understanding/Communication
9
10
11
12
Decision Making/Problem Solving
13
14
15
16
Ability to manage daily tasks (e.g., finances, medications)
17
18
19
20
How often does the person become confused about time or place?
*
Never
Rarely
Sometimes
Often
Always
How would you rate the person's mood or behavior changes recently?
*
1
2
3
4
5
Please describe any specific concerns or examples related to cognitive decline (optional)
Submit Assessment
Should be Empty: