Are you experiencing any of the following?

Do you believe that your memory is general worse today than it was just 2 years ago?
Yes
No
Don't know
Are you frequently misplacing things and unable to retrace your steps to find the object?
Yes
No
Don't know
Are you frequently forgetting the names of people you know very well? For example, are you forgetting the names of your grandchildren or close family members.
Yes
No
Don't know
Is your wife/husband or children expressing concerns about your memory?
Yes
No
Don't know
When driving around town to places you drive to frequently (such as the grocery store, the gym, the hair salon or barber shop, the pharmacy), are you starting to have trouble finding your way back home or getting lost?
Yes
No
Don't know
Do you have difficulty recalling facts in a book or an article you just read? Have you slowed down or stopped reading because you cannot remember what you have read?
Yes
No
Don't know
Can you recall what you did last Saturday? (recall specific details)
Yes
No
Don't know
Do you have difficulty remembering what day of the week this is, or the date of today, or what city, county, and state you are in?
Yes
No
Don't know
Are you repeatedly having difficulty finding the word(s) you need to express yourself?
Yes
No
Don't know
Are you increasingly losing your train of thought when talking with someone?
Yes
No
Don't know
Do you no longer carry out multitasking functions, such as planning and executing a meeting or home gathering, because of poor memory?
Yes
No
Don't know
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