Dementia Benchmark Checklist

Once this checklist is completed the scores will establish a benchmark for all
subsequent checklists. Ideally, these should be completed every 6 months.

Below are situations where your friend or relative has to use his/her memory
and ability to perform daily functions. Indicate how he/she would perform
in each situation.

Date: 7/09/2008


How is this person at… Very Good Good Average Poor Very Poor
Remembering the names of family and friends
Being able to keep track of a conversation
Remembering his/her address and telephone number
Remembering what day and month it is
Remembering where things are usually kept
Remembering things that happened when he/she was young
Knowing how to work familiar appliances around the house
Handling agitation or restlessness
Coping with sad or depressed mood
Dressing and undressing him/her self
Keeping face, hair and clothes neat
Able to feed self, eg. appropriate meal times, cleaning up after meals
Handling money for shopping
Handling other, everyday situations, eg. knowing how much food to buy, knowing how long between visits from family and friends
Overall effort and involvement by caregiver Minimal Low Medium High Very High


This space can be used to record details such as questions you�d like to
ask your specialist, unusual developments or effective ways of handling
behavioural changes.


This information will be collected for educational purposes, however it will remain anonymous.