Memory / Concentration Questionnaire

Liver Gall Bladder Questionaire
The option that best reflects the intensity of each statement.
Never,
Rarely,
Occasionally,
Regularly

The fields denoted with * are compulsory fields

* Name & Surname
* Telephone
* Email
1.
Enter a room and forget what you intended to do?
Never
Rarely
Occasionally
Regularly
2.
You can't remember a phone number and must write it down.
Never
Rarely
Occasionally
Regularly
3.
You forget where you put something (misplaced glasses, keys)
Never
Rarely
Occasionally
Regularly
4.
Find it difficult to follow a movie plot?
Never
Rarely
Occasionally
Regularly
5.
Recite the same story to the same person more than once.
Never
Rarely
Occasionally
Regularly
6.
Forget what you've read. Need to re-read for clarity.
Never
Rarely
Occasionally
Regularly
7.
Have gotten lost, confused, in a place where you've been before.
Never
Rarely
Occasionally
Regularly
8.
Can "word-search." Have to hunt for a word that you should know.
Never
Rarely
Occasionally
Regularly
9.
Are forgetful of recent events, e.g. what you did yesterday.
Never
Rarely
Occasionally
Regularly
10.
Often forget to take the things you need when leaving the house.
Never
Rarely
Occasionally
Regularly
11.
Have to be reminded of things - appointments, promises, etc.
Never
Rarely
Occasionally
Regularly
12.
Have to look in several places to find common household items.
Never
Rarely
Occasionally
Regularly
13.
Forget where you put some object. Have to search to find it.
Never
Rarely
Occasionally
Regularly
14.
Ask the same person the same question twice.
Never
Rarely
Occasionally
Regularly
15.
Forget details of routine procedures.
Never
Rarely
Occasionally
Regularly
16.
Lose track of time.
Never
Rarely
Occasionally
Regularly
17.
Forget or miss appointments.
Never
Rarely
Occasionally
Regularly
18.
Have to ask a listener to remind you what you are talking about.
Never
Rarely
Occasionally
Regularly
19.
Find it hard to remember a new acquaintance's name.
Never
Rarely
Occasionally
Regularly
20.
Check and recheck things like the oven, iron, if a light is on, etc.
Never
Rarely
Occasionally
Regularly
21.
Find it difficult to learn a new skill or game.
Never
Rarely
Occasionally
Regularly