Cognitive Complaints Questionnaire Form
Complete this questionnaire to describe cognitive concerns, their timing, frequency, severity, and impact on daily functioning.
Respondent Information
Full Name
*
First Name
Last Name
Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75+
Relationship to the Person Being Described
*
Please Select
Self
Family Member
Caregiver
Friend
Other
Cognitive Complaint Screening
Primary concern area
*
Memory
Attention
Word-finding
Confusion
Organization
Other
When did the concerns begin?
*
Please Select
Within the last month
1–6 months ago
6–12 months ago
Over a year ago
Not sure
How often do these issues occur?
*
Rarely
Sometimes
Often
Very often
Almost always
Overall concern severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Functional Impact and Follow-up
Impact on daily activities
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Seeking follow-up or evaluation
*
Yes
No
Additional comments
Submit
Should be Empty: