| 1. Memory |
Forgetting names/appointments but remembering later. |
Forgetting recently learned info; asking the same question repeatedly. |
[ ] |
| 2. Planning |
Making occasional errors when balancing a checkbook. |
Significant struggle with monthly bills or following a familiar recipe. |
[ ] |
| 3. Daily Tasks |
Occasionally needing help with new technology settings. |
Trouble driving to a familiar location or managing a lifelong hobby. |
[ ] |
| 4. Orientation |
Forgetting the day of the week but figuring it out later. |
Losing track of dates, seasons, or the passage of time. |
[ ] |
| 5. Visual |
Vision changes related to cataracts or aging. |
Difficulty judging distance or determining color/contrast (tripping). |
[ ] |
| 6. Words |
Sometimes struggling to find the “right” word. |
Stopping mid‑sentence with no idea how to continue; repetitive talk. |
[ ] |
| 7. Placement |
Losing things from time to time (glasses, keys). |
Putting items in unusual places and unable to retrace steps. |
[ ] |
| 8. Judgment |
Making a bad decision once in a while. |
Giving large sums of money to telemarketers; neglecting hygiene. |
[ ] |
| 9. Social |
Feeling weary of social/work obligations sometimes. |
Withdrawing from hobbies or social activities due to apathy. |
[ ] |
| 10. Mood |
Developing very specific ways of doing things. |
Becoming easily upset, suspicious, or fearful when out of routine. |
[ ] |
