Alzheimer's Disease Progression Monitoring Chart

Patient Information

Name: _________________ Date of Diagnosis: _________________ Primary Caregiver: _________________

Cognitive Function Assessment

Memory and Thinking

• Short-term memory: □ Normal □ Mild loss □ Moderate loss □ Severe loss
• Long-term memory: □ Normal □ Mild loss □ Moderate loss □ Severe loss
• Problem-solving ability: □ Normal □ Mildly impaired □ Moderately impaired □ Severely impaired

Daily Living Activities

Basic Activities

• Personal hygiene: □ Independent □ Needs prompting □ Needs assistance □ Dependent
• Dressing: □ Independent □ Needs prompting □ Needs assistance □ Dependent
• Eating: □ Independent □ Needs prompting □ Needs assistance □ Dependent

Complex Activities

• Managing finances: □ Independent □ Needs supervision □ Unable
• Medication management: □ Independent □ Needs supervision □ Unable
• Using transportation: □ Independent □ Needs assistance □ Unable

Behavioral Changes

Mood and Personality

• Anxiety level: □ None □ Mild □ Moderate □ Severe
• Depression signs: □ None □ Mild □ Moderate □ Severe
• Agitation: □ None □ Occasional □ Frequent □ Constant

Social Interaction

• Communication ability: □ Normal □ Slightly impaired □ Moderately impaired □ Severely impaired
• Social engagement: □ Active □ Somewhat active □ Minimal □ Withdrawn

Physical Health Monitoring

Vital Signs

Blood Pressure: / Weight: ___ lbs Sleep patterns: □ Normal □ Disturbed □ Severely disturbed

Notes and Observations

Date: _________________ Observer: _________________ Comments: ________________________________________________

Complete this chart monthly or as advised by healthcare provider