1(A). How often do your patients forget to pay a bill? Often Sometimes Rarely Never Do not know	1(B). How often do your patients think they’ve paid a bill when they haven’t? Often Sometimes Rarely Never Do not know
2(A). How often do your patients misplace things? Often Sometimes Rarely Never Do not know	2(B). How often do your patients think they know where something is but are mistaken? Often Sometimes Rarely Never Do not know
3(A). How often do your patients forget important numbers they should know well (e.g. their phone number, social security number, or address)? Often Sometimes Rarely Never Do not know	3(B). How often do your patients misremember a number they should know well (e.g. remember the wrong phone number, social security number, or address)? Often Sometimes Rarely Never Do not know
4(A). How often do your patients forget the name of someone they know well? Often Sometimes Rarely Never Do not know	4(B). How often do your patients recall an incorrect name when trying to remember the name of someone they know well? Often Sometimes Rarely Never Do not know
5(A). How often do your patients forget to bring something with them that they need? Often Sometimes Rarely Never Do not know	5(B). How often do your patients think they’ve brought something with them that they need when they actually haven’t? Often Sometimes Rarely Never Do not know
6(A). How often do your patients forget that a friend or relative has recently visited them? Often Sometimes Rarely Never Do not know	6(B). How often do your patients think a friend or relative has recently visited when they haven’t? Often Sometimes Rarely Never Do not know
7(A). How often do your patients forget to change their clothes? Often Sometimes Rarely Never Do not know	7(B). How often do your patients think they have changed their clothes when they haven’t? Often Sometimes Rarely Never Do not know
8(A). How often do your patients forget information about their families? For example, how many children, grandchildren, or siblings they have or what their names are? Often Sometimes Rarely Never Do not know	8(B). How often do your patients misremember information about their families? For example, incorrectly remember how many children, grandchildren, or siblings they have or what their names are? Often Sometimes Rarely Never Do not know
9(A). How often do your patients forget to eat a meal? Often Sometimes Rarely Never Do not know	9(B). How often do your patients think they have eaten a meal when they haven’t? Often Sometimes Rarely Never Do not know
10(A). How often do your patients forget to complete an errand? Often Sometimes Rarely Never Do not know	How often do your patients think they have completed an errand when they haven’t? Often Sometimes Rarely Never Do not know
11(A). How often do your patients forget to take their medication? Often Sometimes Rarely Never Do not know	11(B). How often do your patients think they have taken their medication when they haven’t? Often Sometimes Rarely Never Do not know
12(A). How often do your patients forget a birthday or an anniversary that they used to know? Often Sometimes Rarely Never Do not know	12(B). How often do your patients misremember an important date they used to know? For example, they incorrectly remember a birthday or anniversary to be on a different date than it actually is? Often Sometimes Rarely Never Do not know
13(A). How often do your patients forget to buy something they need? Often Sometimes Rarely Never Do not know	13(B). How often do your patients buy the wrong item or avoid buying something because they think they’ve already bought it? Often Sometimes Rarely Never Do not know
14(A). How often do your patients forget to pass on a message? Often Sometimes Rarely Never Do not know	14(B). How often do your patients incorrectly remember part or all of a message when passing it on? Often Sometimes Rarely Never Do not know
15(A). How often do your patients forget all or part of a recent conversation? Often Sometimes Rarely Never Do not know	15(B). How often do your patients incorrectly remember part or all of a recent conversation? Often Sometimes Rarely Never Do not know
16(A). How often do your patients forget what they ate at a recent meal? Often Sometimes Rarely Never Do not know	16(B). How often do your patients think that they ate something at a recent meal that they did not eat? Often Sometimes Rarely Never Do not know
17(A). How often do your patients forget what activities they did in recent days? For example, did not remember they went to the grocery store or post office? Often Sometimes Rarely Never Do not know	17(B). How often do your patients think they did activities in recent days that they did not do? For example, thought they went to the grocery store or post office when they did not? Often Sometimes Rarely Never Do not know
18(A). How often do your patients forget what they did to celebrate important events in the past year? For example, forget what they did for birthdays, Thanksgiving, an anniversary, etc? Often Sometimes Rarely Never Do not know	18(B). How often do your patients incorrectly remember what they did to celebrate important events in the past year? For example, misremember what they did for birthdays, Thanksgiving, etc? Often Sometimes Rarely Never Do not know
19(A). How often do your patients forget to shower? Often Sometimes Rarely Never Do not know	19(B). How often do your patients think they have showered when they haven’t? Often Sometimes Rarely Never Do not know
20(A). How often do your patients forget routes while driving or walking that they used to know well? Often Sometimes Rarely Never Do not know	20(B). How often do your patients think they remember a route they used to know well, but their memory of the route is incorrect? Often Sometimes Rarely Never Do not know