Memory Assessment Questionnaire
Please complete this questionnaire to help us assess your memory and related experiences.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Contact Email Address
*
example@example.com
Highest Level of Education Completed
Please Select
No formal education
Primary school
High school
Vocational training
College/University
Postgraduate
Other
Have you been diagnosed with any medical conditions that may affect memory (e.g., Alzheimer's, stroke, head injury)?
*
Yes
No
Please rate your experience with the following memory-related situations over the past 6 months:
*
Rows
Never
Rarely
Sometimes
Often
Always
Forgetting names of people you know
1
2
3
4
5
Misplacing items (e.g., keys, wallet)
6
7
8
9
10
Forgetting appointments or important dates
11
12
13
14
15
Difficulty recalling recent conversations
16
17
18
19
20
Repeating questions or stories
21
22
23
24
25
Getting lost in familiar places
26
27
28
29
30
How would you rate your overall memory compared to 5 years ago?
*
Much worse
1
2
3
4
Much better
5
1 is Much worse, 5 is Much better
Do you have trouble concentrating or staying focused?
Yes
No
How much do memory problems interfere with your daily life?
*
Not at all
1
2
3
4
Severely
5
1 is Not at all, 5 is Severely
Is there a family history of memory problems or dementia?
Yes
No
Not sure
Please provide any additional comments or concerns regarding your memory.
Submit Assessment
Should be Empty: