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. 2012 Sep 18;2013:160486. doi: 10.1155/2013/160486

Table 1.

Self-reported memory slips for prospective memory items (questions: 1, 3, 5, 7, 10, 12, 14, 16) and retrospective memory items (questions: 2, 4, 6, 8, 9, 11, 13, 15).

(1) Do you decide to do something in a few minutes' time and then forget to do it?
Very often Quite often Sometimes Rarely Never
(2) Do you fail to recognize a place you have visited before?
Very often Quite often Sometimes Rarely Never
(3) Do you fail to do something you were supposed to do a few minutes later even though it is there in front of you, like taking a pill or turning off the kettle?
Very often Quite often Sometimes Rarely Never
(4) Do you forget something that you were told a few minutes before?
Very often Quite often Sometimes Rarely Never
(5) Do you forget appointments if you are not prompted by someone else or by a reminder such as a calendar or diary?
Very often Quite often Sometimes Rarely Never
(6) Do you fail to recognize a character in a radio or television show from scene to scene?
Very often Quite often Sometimes Rarely Never
(7) Do you forget to buy something you planned to buy, like a birthday card, even when you see the shop?
Very often Quite often Sometimes Rarely Never
(8) Do you fail to recall things that have happened to you in the last few days?
Very often Quite often Sometimes Rarely Never
(9) Do you repeat the same story to the same person on different occasions?
Very often Quite often Sometimes Rarely Never
(10) Do you intend to take something with you, before leaving a room or going out, but minutes later leave it behind, even though it is there in front of you?
Very often Quite often Sometimes Rarely Never
(11) Do you mislay something that you have just put down, like a magazine or glasses?
Very often Quite often Sometimes Rarely Never
(12) Do you fail to mention or give something to a visitor that you were asked to pass on?
Very often Quite often Sometimes Rarely Never
(13) Do you look at something without realising you have seen it moments before?
Very often Quite often Sometimes Rarely Never
(14) If you tried to contact a friend or relative who was out, would you forget to try again later?
Very often Quite often Sometimes Rarely Never
(15) Do you forget what you watched on television the previous day?
Very often Quite often Sometimes Rarely Never
(16) Do you forget to tell someone something you had meant to mention a few minutes ago?
Very often Quite often Sometimes Rarely Never