# Memory Assessment

## Quick memory and thinking function assessment

- Are you becoming more forgetful?

Yes  No  Don't know

- Do you have trouble concentrating?

Yes  No  Don't know

- Do you have difficulty performing familiar tasks?

Yes  No  Don't know

- Do you have trouble recalling words or names in conversation?

Yes  No  Don't know

- Do you sometimes forget where you are?

Yes  No  Don't know

- Have family or friends told you that you are repeating questions or saying the same thing over and over again?

Yes  No  Don't know

- Are you misplacing things more often?

Yes  No  Don't know

- Have you become lost when walking or driving in a familiar neighborhood?

Yes  No  Don't know

- Have your family or friends noticed changes in your mood, behavior, personality, or desire to do things?

Yes  No  Don't know

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### Your name

First Name Last Name

### Your email address

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### Your phone number

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### Which US State are you in?

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