Quick memory and thinking function assessment
Are you becoming more forgetful?
Yes
No
Don't know
Do you have trouble concentrating?
Yes
No
Don't know
Do you have difficulty performing familiar tasks?
Yes
No
Don't know
Do you have trouble recalling words or names in conversation?
Yes
No
Don't know
Do you sometimes forget where you are?
Yes
No
Don't know
Have family or friends told you that you are repeating questions or saying the same thing over and over again?
Yes
No
Don't know
Are you misplacing things more often?
Yes
No
Don't know
Have you become lost when walking or driving in a familiar neighborhood?
Yes
No
Don't know
Have your family or friends noticed changes in your mood, behavior, personality, or desire to do things?
Yes
No
Don't know
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