Free tool

Checklist to take to the health worker

About 10 minutes · Fill it in, then print it

This checklist is only in English at the moment. The rest of the site is in eight languages.

This checklist helps you describe what you have noticed, in the order a health worker will want to hear it. Appointments are often short, and it is hard to remember everything while you are worried. Filling this in beforehand means nothing important is left out. Take it with you, or read from it.

The main points

This is not a test and it does not give a diagnosis.
Fill it in with someone who knows the person well.
Tick only the changes that are new, or that are getting worse.
Print it and take it to the appointment.

Get help the same day if confusion comes on suddenly

If someone becomes confused over hours or a few days, that is usually not dementia. It is more often an infection, a reaction to medicine, dehydration or a stroke. These need treating quickly. Go to a health worker straight away rather than filling in this checklist.

Nothing you write here is sent anywhere or saved. It stays on your phone or computer until you close the page, so print it or copy it onto paper before you leave.

1. About the person

Name of the person

Age

Filled in by, and how you know them

Date

2. Memory

Forgets things that happened recently, but remembers things from long ago.
Asks the same question again and again.
Puts things down and cannot find them, and cannot retrace their steps.
Forgets the names of close family or friends.

3. Thinking and planning

Finds it hard to follow steps in order, such as cooking a familiar meal or taking medicine.
Struggles with money, counting change, or paying for things.
Makes decisions that are unsafe, or very unlike them.

4. Words and talking

Stops in the middle of a sentence and cannot find the word.
Uses the wrong word for an everyday thing.
Finds it hard to follow a conversation when more than one person is talking.

5. Place and time

Gets lost in a place they know well, such as near home or on the way to market.
Loses track of the day, the month or the season.

6. Everyday tasks

Needs help with washing, dressing or eating.
Has stopped work, farming, trading or a hobby they always did.
Leaves a fire, stove or tap on, or forgets food that is cooking.
Has become less careful about washing or clothes than they used to be.

7. Mood and behaviour

Has become withdrawn, and avoids people they used to enjoy.
Is easily upset, angry or suspicious without a clear reason.
Sees or hears things that are not there.
Sleeps in the day, and is awake and restless at night.

9. Other health conditions and medicines

Some conditions change the picture, and some are treatable. Tell the health worker about high blood pressure, diabetes, stroke, HIV, epilepsy, poor hearing or sight, head injury, or heavy alcohol use. List every medicine the person takes, including ones bought without a prescription and herbal ones.

10. Anything else you have noticed

Write anything that worries you that is not on this list. One clear example is more useful than a general description, so give the day it happened and what the person did.

11. Questions to ask, and space for the answers

What do you think is causing these changes?
Which tests can be done here, and which need a bigger hospital?
Could something treatable be causing this, such as an infection, a thyroid problem or a vitamin shortage?
What can we do at home to help?
Who do we contact if things get worse?
When should we come back?

This checklist is for information only. It is not a test, it does not give a diagnosis, and it is not a substitute for seeing a health worker. Only a trained health worker can say what is causing these changes.