1. Do you ever go into a room and forget why you went there?
   Never Sometimes About Half the Time Most of the Time Always

2. Do you lose your keys?
   Never Sometimes About Half the Time Most of the Time Always

3. Do you forget where you parked your car in a parking lot?
   Never Sometimes About Half the Time Most of the Time Always

4. Do you have to pay close attention to remember something?
   Never Sometimes About Half the Time Most of the Time Always

5. Do you forget the names of people or places you should know well?
   Never Sometimes About Half the Time Most of the Time Always

6. Do you feel that your brain gets fatigued easily?
   Never Sometimes About Half the Time Most of the Time Always

7. Do you suffer from senior moments?
   Never Sometimes About Half the Time Most of the Time Always

8. Have you stopped trying to learn new things?
   Never Sometimes About Half the Time Most of the Time Always

9. Do you have a hard time staying focused?
   Never Sometimes About Half the Time Most of the Time Always

10. Do you feel lazy or unmotivated to do almost anything?
    Never Sometimes About Half the Time Most of the Time Always

11. Do you "get lost" during a conversation?
    Never Sometimes About Half the Time Most of the Time Always

12. Do you spend your spare time watching TV for 2 or more hours a day?
    Never Sometimes About Half the Time Most of the Time Always

13. Do you have a hard time accepting change?
    Never Sometimes About Half the Time Most of the Time Always

14. Do you have a hard time making a decision?
    Never Sometimes About Half the Time Most of the Time Always

15. Do others tell you that you are getting forgetful?
    Never Sometimes About Half the Time Most of the Time Always

16. Do you ever read something and forget what it is that you just read?
    Never Sometimes About Half the Time Most of the Time Always

17. Do you tend to forget important information that you have to tell somebody?
    Never Sometimes About Half the Time Most of the Time Always

18. Do you have difficulty learning new things?
    Never Sometimes About Half the Time Most of the Time Always

19. Do you have to interrupt people in conversation because you are afraid you might forget?
    Never Sometimes About Half the Time Most of the Time Always

20. Have you ever thought that you might be coming down with Alzheimer’s Dementia?
    Never Sometimes About Half the Time Most of the Time Always