MEMORY AND BEHAVIOR PROBLEMS CHECKLIST (Public Domain) Reference: Zarit, S. H.; Todd, P. A. and Zarit, J. M. (1982). Subjective burden of husbands and wives as caregivers: A longitudinal study. Gerontologist, 26:3, 260-266. BEHAVIORS FREQUENCY Never has, but hasonce ——has3-6 occurs Occurs not in cr twice times in daily past in past past or more week week, week often a7 Wondering or geting lost 0 7 2 3 4 b Asking repetitive questions 9 1 2 3 4 ©. Having difficulty remembering ° 1 2 3 4 hhow to do simple tasks . 4. Being suspicious or accusative ° ’ 2 3 4 Losing or misplacing things ° 1 2 3 4 £ Not recognizing familiar people 0 1 2 3 4 2. Forgetting whet day itis ° ' 2 3 4 h, Not completing tasks ° 1 2 3 « Destroying property 0 1 2 3 4 J Having objection, rude or 0 1 2 3 4 embarrissing behavior Waking me up at night 0 1 2 3 4 1. Being constantly talkanve or restless 0 1 2 3 4 m. Packing up special items 0 1 2 3 4 a Engaging in potentially dangerous behaviors ° ' 2 3 4 to others (describe) ». Engaging in potentially dangerous behaviors 0 ' 2 3 4 to self (describe)BEHAVIORS FREQUENCY Never has, but has once has 3-6 occurs Occurs notin = ortwice—ttimesin daily past in past past ‘or more week werk week often p. Hearing voices from the past ° 1 2 3 4 q._ Re-living siruation from the ° 1 2 3 4 past 1 Seeing or hearing things that 0 1 2 3 4 are not there (hallucinations) Difficulty dressing self ° 1 2 3 a tDifficulty feeding self 6 1 2 3 4 v. Difficulty bathing or showering ° 1 2 3 4 ¥. Difficulty shaving or putting o 1 2 3 4 fon make-up . w. Incontinent of bowel or bladder ° 1 a 3 4 x. Difficulty preparing meals ° 1 1 3 4 y Difficulty cleaning the house ° 1 2 3 4 2. Difficulty using the phone ° 1 2 3 4 a2. Difficulty handling money ° 1 3 4 bb. Difficulty shopping 0 1 3 4BEHAVIORS TOLERANCE Tean Ten Tear Taont ean n0 tolerate tolerate tolerate know longer this this this how tolerate behav behavior, behavior, much ths when it bout butit longer behavior ecurs bothers bothers Team and have mea mes tolerate toe hie ‘ot this something behavior about a. Wandering or getting lost 0 1 2 3 4 b. Asking repetitive questions o 1 2 3 4 © Having difficulty remem- 0 1 2 3 4 beringhow to do simple tasks 4. Being suspicious or accusative 0 1 a 3 4 Losing or mispiacing things 0 1 2 3 a f. Not recognizing familiar ° 1 2 3 2 people 2 Forgetting what day itis o 1 2 2 4 h. Not completing tasks ° 1 7 3 4 1. Destroying propery ° 1 2 3 4 } Having objection, mide or 0 1 2 3 4 embarrassing behavior k Waking me up at night o 1 2 3 4 Being constantly talkative ° 1 2 3 4 or restless m Packing up special items ° 1 2 3 4 1. Engaging in potentially 0 1 2 Z) 4 dangerous behaviors 10 others (describeBEHAVIORS —_— Team tolerate this bochavior TOLERANCE Tear tolerate ahs behavior, butt bothers tne Tear tolerate this behavior, bute bothers Jot Tdon't know how much longer Tean tolerate vhs behavior Tean no longer tolerate this behavior ‘and have todo about it bb. Engaging in potentially dangerous behaviors to self (describe) Hearing voices from the past 5 Re-living situation from the past ‘Seeing or hearing things that are ‘not there (hallucinations) Difficulty dressing self Difficulty feeding self Difficulty bathing or showering Diffieulry shaving or putting on make-up Incontinent of bowel or bladder Dithculyy preparing meals Difficulty cleaning the house Difficulty using the phone Difficulty handling money Difficulty shopping e