Modified from DSM IV. Diagnostic Criteria for dementia of The Alzheimer's type
Memory Screening Questionnaire
Please complete this questionnaire below (consisting of 10 questions) to screen for memory problems
1
Short-term memory impairments, such as inability to remember what to do or what to pick up.
2
Often asking the same questions.
3
Often losing your belongings which disturbs daily life.
4
Inability to remember the names of close relatives or family members.
5
Naming items that are regularly used incorrectly.
6
Inability to learn new knowledge.
7
Inability to use everyday devices, such as unable to open the faucet, unable to open door knob or fasten the buttons.
8
Getting lost in familiar places or entering the wrong room in own home.
9
Inability to work or perform routine tasks.
10
Changing in mood, such as increased irritability, becoming more sluggish or more irritable.
Your responses are anonymous and will be kept confidential.
This questionnaire does not collect personally identifiable information. By clicking to submit your responses, you agree to the terms of use.
Reference:
- Modified from DSM IV. Diagnostic Criteria for dementia of The Alzheimer's type