Does your loved one frequently repeat the same questions or stories within a short time?

Do they struggle to remember recent events, conversations, or what they ate for breakfast?

Are they getting lost or disoriented in familiar places (home, neighborhood, or stores)?

Do they have trouble recognizing family members or close friends?

Have they shown confusion about what day, month, or year it is?

Do they mix up names of everyday objects or have difficulty finding the right words?

Are they forgetting how to perform familiar tasks (using the phone, remote control, or appliances)?

Do they need significant help with dressing, bathing, or personal hygiene?

Are they forgetting to eat, drink, or prepare simple meals?

Do they have difficulty managing medications without full supervision?

Have they stopped bathing or changing clothes regularly due to forgetting or resistance?

Do they need constant cues or hands-on help to complete basic daily routines?

Are they having trouble with toileting or managing incontinence?

Have they wandered away from home or become lost in the past year?

Do they try to leave the house at inappropriate times (nighttime, bad weather)?

Are they unsafe when using the stove, oven, or other kitchen appliances?

Do they leave doors unlocked or forget to turn off water / faucets?

Have they had falls or accidents due to confusion or poor judgment?

Do you worry they may unintentionally harm self or others because of memory loss?

Is constant supervision needed to keep them safe throughout the day and night?

Do they become agitated, anxious, or restless, especially in the late afternoon or evening?

Have they shown increased suspicion, paranoia, or accusations toward family members?

Do they experience hallucinations (seeing or hearing things that aren’t there)?

Are they having trouble sleeping or frequently waking up confused at night?

Do they resist care or become combative when helped with daily tasks?

Have their mood swings or emotional outbursts increased?

Do they withdraw from social activities or seem apathetic most of the time?

Is your family caregiver feeling exhausted or overwhelmed by the level of supervision required?

Are you worried about leaving your loved one alone, even for short periods?

Has caregiving started to affect your own health, work, or relationships?

Do you feel your loved one’s needs are beyond what can be safely managed at home or in standard assisted living?

Would your loved one benefit from a secure, structured environment designed specifically for memory impairment?

Are you open to exploring a community with 24/7 specialized dementia care and trained staff?

Are you starting to consider a community with 24/7 specialized dementia care and trained staff?

On a scale of 1–5, how concerned are you about your loved one’s current safety and quality of life due to memory changes?

1 = not concerned, 5 = extremely concerned.