Answer the questions below to see whether a memory evaluation may be beneficial for you or a loved one.
Memory Screening Questionnaire
This questionnaire is not intended to diagnose dementia or any medical condition. It is designed to help identify potential memory concerns and determine whether further evaluation may be beneficial.
Over the past 12 months, have you noticed any of the following?
□ Frequently forgetting appointments or important dates
□ Repeatedly asking the same questions
□ Difficulty remembering recent conversations or events
□ Misplacing items more often than usual
□ Trouble finding the right words during conversations
□ Difficulty following conversations, television programs, or written information
□ Problems managing medications, finances, or household responsibilities
□ Becoming confused in familiar places
□ Increased difficulty learning new information
□ Changes in judgment or decision-making
□ Changes in mood, personality, or behavior that concern you or your family
□ Family members or friends have expressed concern about your memory
Results
0-2 checked boxes
Memory changes may be consistent with normal aging. Continue monitoring your symptoms and discuss any concerns with your healthcare provider.
3-5 checked boxes
Some of your responses suggest memory or cognitive changes that may benefit from further discussion with a healthcare professional.
6 or more checked boxes
Your responses indicate concerns that may warrant a comprehensive memory evaluation.
Important Note
This questionnaire is only a screening tool and cannot diagnose dementia, Alzheimer’s disease, or other medical conditions. If you have concerns about memory, thinking, or daily functioning, we encourage you to schedule an appointment with the Family Medicine Center Memory Clinic.
We are here to help you navigate memory concerns with confidence and compassion. Talk to us: 702-9310
Looking for more information? Return to the Memory Clinic Resource Center to explore additional articles, videos, FAQs, and resources for patients and families.