Keep your loved one's brain health top of mind with this easy-to-use screening tool.

• ✅ Quick and simple reference: A one-page form that helps identify signs of memory or thinking changes that may need medical attention.

• ✅ Great to address during office visit: Helps you and your loved one's healthcare provider use clear, objective information to develop a personalized care plan.

• ✅ Not for self-diagnosis: This is not meant to be administered at home. Always consult with a qualified healthcare provider to interpret the results.

Disclaimer: This resource is provided for informational purposes only. Downloading or using this form does not constitute medical advice, nor does it establish a doctor-patient relationship.