1. |
Compared to one year ago, do you feel that
your memory has declined substantially? |
2. |
Do others tell you that you tend to repeat
questions over and over? |
3. |
Have you been misplacing things more
often? |
4. |
Do you find that lately you are relying more
on written reminders (e.g., shopping lists, calendars)? |
5. |
Do you need more help from others to remember
appointments, family occasions or holidays? |
6. |
Do you have more trouble recalling names,
finding the right word, or completing sentences? |
7. |
Do you have more trouble driving (e.g., do you
drive more slowly, have more trouble at night, tend to get lost, have
accidents)? |
8. |
Compared to one year ago, do you have more
difficulty managing money (e.g., paying bills, calculating change,
completing tax forms)? |
9. |
Are you less involved in social
activities? |
10. |
Has your work performance (paid or volunteer)
declined significantly compared to one year ago? |
11. |
Do you have more trouble following the news,
or the plots of books, movies or TV shows, compared to one year
ago? |
12. |
Are there any activities (e.g., hobbies, such
as card games, crafts) that are substantially more difficult for you now
compared to one year ago? |
13. |
Are you more likely to become disorientated,
or get lost, for example when traveling to another city? |
14. |
Do you have more difficulty using household
appliances (such as the washing machine, VCR or computer)? |