Annual Wellness Visit Memory Screening Questionnaire Form
Please complete the Annual Wellness Visit Memory Screening Questionnaire Form to help assess memory and cognitive function. Answer each question as accurately as possible.
How often do you have trouble remembering recent events or conversations?
*
Never
Rarely
Sometimes
Often
Always
How often do you misplace items such as keys, glasses, or your phone?
*
Never
Rarely
Sometimes
Often
Always
How confident are you in your ability to remember appointments or scheduled events?
*
1
2
3
4
5
In the past month, how often have you had difficulty finding the right word during a conversation?
*
Never
Rarely
Sometimes
Often
Always
How often do you forget names of people you have recently met?
*
Never
Rarely
Sometimes
Often
Always
How often do you get confused about the day or date?
*
Never
Rarely
Sometimes
Often
Always
How often do you need reminders from others to complete daily tasks?
*
Never
Rarely
Sometimes
Often
Always
Please rate your overall memory compared to one year ago.
*
Much worse
1
2
3
4
Much better
5
1 is Much worse, 5 is Much better
How often do you have trouble following a conversation in a group?
*
Never
Rarely
Sometimes
Often
Always
Is there anything else you would like to share regarding your memory or cognitive function?
Submit
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