Memory Screening
Questionnaire

Please complete this questionnaire below (consisting of 10 questions) to screen for memory problems
1 Short-term memory impairments, such as inability to remember what to do or what to pick up.
2 Often asking the same questions.
3 Often losing your belongings which disturbs daily life.
4 Inability to remember the names of close relatives or family members.
5 Naming items that are regularly used incorrectly.
6 Inability to learn new knowledge.
7 Inability to use everyday devices, such as unable to open the faucet, unable to open door knob or fasten the buttons.
8 Getting lost in familiar places or entering the wrong room in own home.
9 Inability to work or perform routine tasks.
10 Changing in mood, such as increased irritability, becoming more sluggish or more irritable.
Reference:
  • Modified from DSM IV. Diagnostic Criteria for dementia of The Alzheimer’s type