Healthy Aging Brain Center - Self Report Monitor

The HABC Monitor is an instrument developed for the purpose of assessing and monitoring symptoms of dementia over time. The instrument covers the four clusters of dementia symptoms: cognitive, functional, behavioral and mood, and caregiver stress. The HABC Monitor depends on self-reports and informal caregiver reports that do not require the presence of a clinician or facilitator and can be completed through paper, web, or telephone based templates.
Total Score: 0
Over the past 2 weeks how often did you have problems with: Not at all
(0-1 day)
Several days
(2-6 days)
Most days
(7-11 days)
Almost Daily
(12-14 days)
Judgment or decision-making.
Less interest or pleasure in doing things, hobbies, or activities.
Repeating the same things over and over such as questions or stories.
Learning how to use a tool, appliance, or gadget.
Forgetting the correct month or year.
Handling complicated financial affairs such as balancing checkbook & paying bills.
Remembering appointments.
Thinking or memory.
Planning, preparing or serving meals.
Taking medications in the right dose at the right time.
Walking or physical ambulation.
Bathing.
Shopping for personal items like groceries.
Driving.
Falling and tripping.
Housework or household chores.
Feeling down, depressed, or hopeless.
Feeling lonely.
Resisting help from others or getting agitated.
Feeling anxious, nervous, tense, fearful or panic.
Believing others are stealing from you or planning to harm you.
Hearing voices, seeing things or talking to people who are not there.
Poor appetite or overeating.
Falling asleep, staying asleep, or sleeping too much.
Acting impulsively, without thinking through the consequences of your actions.
Wandering, pacing, or doing things repeatedly.
Quality of life.
Your financial future.
Your mental health.
Your physical health.
After printing, please bring the completed form(s) to your appointment where it will be scored and discussed during your office visit.