Memory Checklist

Mark an X in the box that best describes how often you experience the following problems.

Problem

Rarely
(Less than monthly)

Sometimes
(At least monthly)

Often
(At least weekly)

Always
(At least daily)

Fail to recognize places you have been before

       

Forget something you were told recently and had to be reminded of it

       

Forget when something happened, wondering whether it was yesterday or last week

       

Forget where you put items like house keys or wallet

       

Forget whether you did something, such as lock the door or turn off the lights or oven

       

In conversation, forget what you were talking about

       

Unable to remember a word or name, even though it's "on the tip of your tongue"

       

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.