Memory Difficulty Self-Assessment Form
Evaluate your recent experiences with memory and concentration using this self-assessment form.
How often do you have trouble remembering recent events?
*
1
2
3
4
5
How frequently do you forget names of people you know?
*
1
2
3
4
5
In the past month, how often have you misplaced items like keys, phone, or wallet?
*
1
2
3
4
5
How often do you find it difficult to concentrate on tasks?
*
1
2
3
4
5
How would you rate your overall memory compared to a year ago?
*
1
2
3
4
5
Please indicate how much you agree with the following statements about your memory.
*
Rows
Never
Rarely
Sometimes
Often
Always
I forget appointments or planned activities
1
2
3
4
5
I lose track of conversations
6
7
8
9
10
I need reminders for daily tasks
11
12
13
14
15
I struggle to recall instructions
16
17
18
19
20
How long have you noticed memory difficulties?
*
Please Select
Less than 1 month
1–6 months
6–12 months
Over a year
Not sure
How much do memory difficulties impact your daily life?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Do you feel your memory difficulties are getting worse?
*
Yes
No
Not sure
Is there anything else you would like to share about your memory experiences?
Submit Self-Assessment
Should be Empty: