Dementia Care Checklist
Use this checklist to assess and monitor the care needs, safety, and well-being of individuals living with dementia.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person's Full Name
*
First Name
Last Name
Relationship to Person with Dementia
*
Please Select
Family Member
Professional Caregiver
Friend
Other
Who is completing this checklist?
*
First Name
Last Name
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Assessment of Daily Living Activities (ADLs)
*
Rows
Independent
Needs Some Assistance
Fully Dependent
Bathing
1
2
3
Dressing
4
5
6
Eating
7
8
9
Toileting
10
11
12
Mobility (moving around)
13
14
15
Managing Finances
16
17
18
Home Safety Checklist (Check all that apply)
Doors and windows are secured as needed
Hazardous items (cleaners, sharp objects) are stored safely
Adequate lighting in all areas
Emergency contact numbers are visible
Fall prevention measures in place (no loose rugs, grab bars)
Other
Cognitive and Behavioral Observations
*
Rows
Never
Sometimes
Often
Forgets recent events
19
20
21
Wanders or gets lost
22
23
24
Shows agitation or aggression
25
26
27
Experiences mood changes
28
29
30
Has trouble recognizing familiar people
31
32
33
Medication Management
*
Manages medications independently
Needs reminders or assistance
Medications managed by caregiver
Nutrition and Hydration
*
Eats and drinks independently
Needs reminders or help
Requires full assistance
Social Engagement
Participates in activities/socializes regularly
Occasionally involved in activities/socializing
Rarely or never participates/socializes
Caregiver Concerns (select all that apply)
Increasing care needs
Challenging behaviors
Safety risks
Lack of support/resources
Other
Additional Notes or Observations
Submit Checklist
Should be Empty: