Email *

Full Name *

Do you have memory loss? *

Yes

No

If so, is your memory loss worse than a few years ago? *

Yes

No

Do you repeat questions or statements or stories in the same day? *

Yes

No

Do you forget important events or appointments? *

Yes

No

Do you misplace items more than once a month? *

Yes

No

Do you suspect others are moving, hiding or stealing items when you cannot find them? *

Yes

No

Do you frequently have trouble knowing the day, date, month, year, time? OR have to use cues like the newspaper or the calendar to know the day and date more than once a day? *

Yes

No

Do you become disoriented in unfamiliar places? *

Yes

No

Do you become more confused outside the home or when traveling? *

Yes

No

Excluding physical limitations (e.g., tremor, weakness, etc) do you have trouble handling money (tips, calculating change)? *

Yes

No

Excluding physical limitations (e.g., tremor, weakness, etc), do you have trouble paying bills or doing finances OR Are family members taking over finances because of concerns about ability? *

Yes

No

Do you have trouble remembering to take medications or tracking medications taken? *

Yes

No

Do you have difficulty driving? OR Have you stopped driving for reasons other than physical limitations? *

Yes

No

Are you having trouble using appliances (e.g. microwave, oven, stove, remote control, telephone, alarm clock)? *

Yes

No

Excluding physical limitations, are you having difficulty in completing home repair or other home related tasks (housekeeping)? *

Yes

No

Excluding physical limitations, have you given up or significantly reduced activities such as golfing, dancing, exercising, or crafts? *

Yes

No

Are you getting lost in familiar surroundings (own neighborhood)? *

Yes

No

Do you have a decreased sense of direction? *

Yes

No

Do you have trouble finding words other than names? *

Yes

No

Do you confuse names of family members or friends? *

Yes

No

Do you have difficulty recognizing people familiar to you? *

Yes

No

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