1 – Never
2 – Very Rarely
3 – Occasionally
4 – Quite Often
5 – Very Often
¹
1
2
3
4
5
1
Do you find you forget why you went from one part of the house to the other?
2
Do you find you forget whether you've turned off a light or a fire or locked the door?
3
Do you fail to hear people speaking to you when you are doing something else?
4
Do you find you forget appointments?
5
Do you find you accidentally throw away the thing you want and keep what you meant to throw away?
6
Do you find you forget what you came to the shops to buy?
7
Do you forget to take your keys with you?
8
Do you forget passwords you need to remember?
9
Do you receive a delivery and forget what you ordered?
10
Do you call people by the wrong name?
11
In conversations, do you forget people's name even when you know them well?
12
Do you get the dates of things mixed up?
13
Do you find you go to put objects in the wrong place, like putting something from the cupboard in the fridge?
14
Do you leave home and later realise you have forgotten something you intended to bring with you?
15
Do you think something is missing, only to later see it where you had already looked?
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.