Dementia/Alzheimer’s Questionnaire

Have you noticed a change in your loved one’s behavior, such as:

Mobility/Cognition Test:

On a separate piece of paper draw a standard large circle like the one below for your loved one. You will then ask them to draw all the numbers of a clock in their correct positions (don’t instruct your loved one on the placement of the numbers). Once completed, verbally ask your loved one to set a time, for example: “Please set the hands so that the time is 10 past 11 o’clock.” The ability to accurately draw the clock numbers and set the hands of the clock according to the request, is a sign of good cognitive function. If your loved one experiences problems with these two tasks, it could indicate possible Dementia/Alzheimer’s.

Copyright 2005. The AD8: The Washington University Dementia Screening Test (“Eight-item Interview to Differentiate Aging and Dementia”) is a copyrighted instrument of Washington University, St. Louis, Missouri.

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