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: 28/08/2008

Name:

Notes

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.

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

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if you want advice please see your treating physician.

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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

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