1.
I frequently forget recent conversations or appointments
Yes
No
2.
Others have commented on my memory lately
Yes
No
3.
I often misplace items or get lost in familiar places
Yes
No
4.
I find it harder to plan or organize tasks than before
Yes
No
5.
Managing bills, schedules, or daily tasks has become difficult
Yes
No
6.
I feel easily overwhelmed when making decisions
Yes
No
7.
I’ve noticed increased irritability, mood swings, or fatigue
Yes
No
8.
I’ve withdrawn from social or work activities that I once enjoyed
Yes
No
9.
I’ve experienced balance issues or frequent falls
Yes
No
10.
I’ve had episodes of confusion or unexplained memory lapses
Yes
No
11.
I have sleep apnea, thyroid problems, or vitamin deficiencies
Yes
No
12.
I’ve had a head injury, seizure, or stroke in the past year
Yes
No
13.
I engage in puzzles or mentally stimulating activities
Yes
No
14.
I get a good night’s sleep most nights
Yes
No
15.
I’m aware of steps I can take to reduce my dementia risk
Yes
No
