Lewy Body Dementia Symptom Checklist
Use this checklist to document and assess symptoms related to Lewy Body Dementia for yourself or someone you care for.
Patient's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient
*
Please Select
Self
Family Member
Caregiver
Healthcare Professional
Other
Cognitive and Behavioral Symptoms (rate frequency/severity for each)
*
Rows
Never
Rarely
Sometimes
Often
Always
Memory loss
1
2
3
4
5
Difficulty with attention or concentration
6
7
8
9
10
Confusion or disorientation
11
12
13
14
15
Visual hallucinations
16
17
18
19
20
Delusions (false beliefs)
21
22
23
24
25
Rapid mood changes
26
27
28
29
30
Motor Symptoms (rate frequency/severity for each)
*
Rows
Never
Rarely
Sometimes
Often
Always
Slowness of movement (bradykinesia)
31
32
33
34
35
Muscle stiffness or rigidity
36
37
38
39
40
Tremors
41
42
43
44
45
Shuffling walk
46
47
48
49
50
Frequent falls or balance issues
51
52
53
54
55
Sleep and Autonomic Symptoms (select all that apply)
Acting out dreams (REM sleep behavior disorder)
Daytime sleepiness
Difficulty swallowing
Constipation
Fainting or dizziness
Urinary problems
Other (please specify)
How often do symptoms fluctuate (change in severity or type throughout the day)?
*
Never
1
2
3
4
Very Frequently
5
1 is Never, 5 is Very Frequently
Please describe any additional symptoms or concerns not listed above.
Contact Email (optional, for follow-up if needed)
example@example.com
Submit Checklist
Should be Empty: