Functional Health Diagnostics

Memory / Concentration Questionnaire

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

Name & Surname

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