1
1
Do you forget family member's names?
2
2
Do you repeat yourself or do others tell you that you repeat yourself?
3
3
Does your family complain that they are always repeating themselves to you?
4
4
Have you gotten lost driving or gotten into more than one recent car accident?
5
5
Are you having difficulty handling your personal finances or paying bills properly?
6
6
Do you miss appointments or dates?
7
7
Do you confuse dates?
8
8
Do you forget to take your medication or supplements as directed?
9
9
Do you have conversational difficulties?
10
10
Do you make mistakes at work or in your daily tasks?
11
11
Do you have difficulty following a movie or book?
12
12
Are you having a tough time recalling or understanding current events?
1
1
Are you depressed or sad?
2
2
Do you have difficulty concentrating?
3
3
Do you feel guilty or helpless?
4
4
Are you irritable or restless?
5
5
Have you lost interest in activities or hobbies?
6
6
Do you suffer from significant stress or anxiety?
7
7
Are you worried about your memory?
8
8
Do you misplace things (i.e. car keys, reading glasses)?
9
9
Do you suffer from irrational fears?
10
10
Do you have panic attacks?
11
11
Do you forget your shopping list or forget items at the store?
12
12
Are you disorganized?
13
13
Did you have difficulty focusing in school when you were younger?
14
14
Were you fidgety when you were younger, or are you still?
15
15
When reading a book or magazine, do you forget what you have read?
16
16
Do you have sleep difficulties like night time awakenings, you can't fall asleep, or you can't stay asleep?
18
18
Do you have headaches upon awakening?
19
19
Are you excessively sleepy during the day?
20
20
Do you experience any symptoms that keep you awake?
21
21
Are you experiencing the symptoms of menopause?
22
22
Do you suffer from mood swings?
23
23
Do you feel forgetful, absent minded, or suffer from brain fog?
24
24
Are you easily distracted?
25
25
Do food cravings accompany changes in your thinking or memory?