Step:
1
/
5
What is your gender?
a Male
b Female
c Other
What is your age range?
a 18-20
b 20–27
c 28–35
d 36–45
e 46–55
f 56–65
g 65+
Have you ever practiced exercises aimed at improving your memory skills?
a Yes
b Unsure
c No
How often do you find yourself forgetting a word you usually know well?
a Frequently
b Sometimes
c Almost never
How often do you forget the names of new people you meet?
a Very often
b Occasionally
c Almost never
How regularly do you misplace common items like your keys or phone?
a Daily
b Weekly
c Rarely
d Never
Compared to five years ago, do you feel your memory has improved, stayed the same, or declined?
a Improved
b About the same
c Declined
Do distractions often make it hard for you to focus on tasks?
a Very often
b Sometimes
c Rarely
d Never
How often do you forget special occasions such as birthdays or anniversaries?
a Almost never
b Occasionally
c Frequently
d Very frequently
When you recall a recent trip or event, how detailed are your memories?
a Very detailed
b Most important moments
c Somewhat fuzzy
d Barely remember
I find it easy to concentrate when learning new material.
a Strongly disagree
b Disagree
c Neutral
d Agree
e Strongly agree
I can remember and follow multiple instructions accurately.
a Strongly disagree
b Disagree
c Neutral
d Agree
e Strongly agree
I recall recent experiences clearly and with good detail.
a Strongly disagree
b Disagree
c Neutral
d Agree
e Strongly agree
I often use notes or memory tricks to help remember things.
a Strongly disagree
b Disagree
c Neutral
d Agree
e Strongly agree
Do you sometimes forget to do tasks you had planned, like appointments or chores?
a Yes
b No
Are you confident in recalling facts or knowledge you have learned over time?
a Yes
b No
When you learn new information, do you often forget it shortly afterward?
a Yes
b No
Is it difficult for you to hold a phone number or address in your mind long enough to write it down?
a Yes
b No
Do you sometimes forget how to perform tasks you are familiar with, such as cooking or using your phone?
a Yes
b No
How confident are you in your ability to remember important details?
a Very confident
b Somewhat confident
c Not very confident
d Not confident at all
How often do you need to double-check information because you forgot it the first time?
a Very often
b Sometimes
c Rarely
d Never
Does stress or tiredness make it harder for you to remember things?
a Much harder
b Somewhat harder
c Not really
d No difference
How often do you forget what you intended to say mid-conversation?
a Very often
b Sometimes
c Rarely
d Never
How often do you forget where you parked your car or left your bike?
a Very often
b Sometimes
c Rarely
d I don’t own a car or bike
Do you frequently rely on others to remind you of important things?
a Yes, often
b Sometimes
c Almost never
How often do memory lapses cause frustration or upset?
a Often
b Sometimes
c Never
Does forgetting important information worry you about your memory health?
a Yes
b No
When multitasking, do you find it harder to remember important details?
a Yes
b No
Do distractions negatively affect your ability to remember information?
a Yes
b No
Do you find it easier to recall information when it's presented in a specific order?
a Yes, much easier
b Slightly easier
c No difference
d Harder, actually
When trying to memorize something, do you mentally visualize it?
a Always
b Often
c Rarely
d Never
How well can you recall what someone just said in a conversation?
a Very well
b Pretty well
c Somewhat
d Poorly
When reading, how often do you forget what you just read?
a Frequently
b Occasionally
c Rarely
d Never
Can you easily remember numbers like PIN codes or phone numbers?
a Very easily
b With effort
c Only for a short time
d Not at all
Do you tend to remember emotional experiences more vividly?
a Yes, strongly
b Sometimes
c Rarely
d No
When someone gives you directions verbally, how well do you remember them?
a Very well
b Somewhat well
c Poorly
d I forget them immediately
How easily can you remember names after hearing them once?
a Very easily
b Sometimes
c Rarely
d Never
When you walk into a room, do you ever forget why you entered?
a Frequently
b Occasionally
c Rarely
d Never
Do you feel your memory is stronger for visual or verbal information?
a Visual
b Verbal
c Both equally
d Neither
How accurately can you recall numeric sequences or patterns?
a Very accurate
b Mostly accurate
c Sometimes inaccurate
d Frequently inaccurate
How well do you remember new words or vocabulary recently learned?
a Very well
b Moderately well
c Poorly
d Not at all
Do you find it easier to remember facts linked to images or stories?
a Yes
b No
How often do you review or repeat new information to help memorize it?
a Always
b Often
c Sometimes
d Rarely
e Never
How often do you forget the sequence of steps when performing a routine task?
a Often
b Sometimes
c Rarely
d Never
How quickly can you recall information you studied recently?
a Immediately
b After some thought
c With difficulty
d Not at all
Do you use specific memory strategies (like chunking or mnemonics) to help you remember?
a Yes
b No
How much harder is it to remember things when distracted?
a Much harder
b Slightly harder
c No difference
How often does memory difficulty interfere with your daily tasks or work?
a Often
b Occasionally
c Never
Have you noticed changes in your memory during illness or lack of sleep?
a Significant change
b Minor change
c No change
How do you think your memory compares to others your age?
a Much better
b About average
c Worse
