Purpose: Most dementia tracking focuses on individual days. This sheet zooms out to the monthly picture —
the slow changes that are invisible day-to-day but obvious when you compare month to month.
After 6 months of entries you have a clinical picture more useful than many formal assessments.
Patient name
Month / Year
Current dementia stage estimate
Completed by
MONTHLY PHYSICAL MEASUREMENTS
Weight (kg or lb)
Change from last month:
Falls this month
Injuries if any:
Hospital / ER visits
Reason:
Infections / illness
UTI, chest, other:
FUNCTIONAL DOMAIN ASSESSMENT — Rate each domain 1–5 this month, then compare to last month
| Domain | Rating this month (1=severe difficulty · 5=managing well) | Last month rating | Trend (↑ ↓ →) | Specific observations |
|---|---|---|---|---|
| Memory & recall | 1 · 2 · 3 · 4 · 5 | |||
| Language & communication | 1 · 2 · 3 · 4 · 5 | |||
| Mobility & balance | 1 · 2 · 3 · 4 · 5 | |||
| Personal care (bathing, dressing) | 1 · 2 · 3 · 4 · 5 | |||
| Eating & appetite | 1 · 2 · 3 · 4 · 5 | |||
| Sleep quality | 1 · 2 · 3 · 4 · 5 | |||
| Mood & emotional wellbeing | 1 · 2 · 3 · 4 · 5 | |||
| Behaviour (agitation, wandering) | 1 · 2 · 3 · 4 · 5 | |||
| Social engagement | 1 · 2 · 3 · 4 · 5 | |||
| Pain level (5 = minimal pain) | 1 · 2 · 3 · 4 · 5 |
OVERALL TRAJECTORY THIS MONTH
Overall assessment (circle one):
WHAT CHANGED THIS MONTH — factors that may have influenced the trajectory
| Change introduced this month | Apparent effect (positive / negative / none) |
|---|---|
| New medication or dose change | |
| New caregiver or change in care hours | |
| Routine disruption (travel, visitors, illness) | |
| New activity or intervention tried | |
| Other: |
INSIGHTS & PLANNING
What worked well this month — keep doing this
What didn't work or made things worse — change this
Quality of life: what brought genuine joy or engagement?
Items to raise at next doctor appointment
One-line summary of this month
If you notice a sudden acute change — significant new confusion, agitation, or decline in function — rule out a physical cause first: UTI, chest infection, medication change, or pain. These are treatable and frequently produce dramatic behavioural and cognitive changes that look like dementia progression but resolve with treatment. Call the family doctor. · gurjotnarwal.com/how-i-can-help