Self-Assessment Questionnaire
to assess if your forgetfulness may require further attention
These questions are designed to evaluate your memory ability and is not meant to be a diagnostic tool for any disease condition. If you are concerned about your memory, please consult your healthcare professional for further advice. This questionnaire is for information only and not a substitute for a consultation with a qualified professional.
Please answer the 5 questions below:
1. Do you or your loved one often forget where things are placed?
Eg. misplacing items or belongings at home.
2. Do you or your loved one often find it difficult to recall the names of good friends?
Eg. have trouble recalling names of your family / extended family members.
3. Do you or your loved one often find it difficult to follow and recall conversations?
Eg. you may stop in the middle of a conversation and have difficulty continuing the
conversation or repeating yourself.
4. Do you or your loved one often find it difficult to find the right words to express yourself?
Eg. not being able to find the right words to describe what you want to say.
5. Have the above symptoms persisted on most days for more than 6 months?
If you or your loved one answer ‘YES’ to any question from 1-4 and a ‘YES’ to Question 5,
you may be at risk of mild cognitive impairment or Alzheimer’s disease.
Please see a doctor to determine the possible cause. Early diagnosis gives you
a chance to seek treatment and plan for your future.
