Memory Questionnaire (AD8)

1

Please answer this 8-question survey. “YES” means that there has been a change in the last several years caused by a memory or thinking problem

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2

Do you have problems with thinking? * This field is requiredFor example, problems with making decisions or problems with judgment

YesNo

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3

Do you have less interest in hobbies or activities?* This field is required

YesNo

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4

Do you repeat the same things over and over? * This field is requiredFor example, repeating questions or stories

YesNo

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5

Do you have trouble learning how to use tools, appliances, or gadgets?* This field is required

YesNo

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6

Do you forget the correct month or year?* This field is required

YesNo

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7

Do you have trouble handling complicated financial matters?* This field is requiredFor example, checking your bank activity or making sure that you are not overcharged

YesNo

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8

Do you have trouble remembering appointments?* This field is required

YesNo

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9

Do you have daily problems with thinking or memory? * This field is required

YesNo

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10

Email* This field is requiredWe will send a copy of your quiz to the email provided below

example@example.com

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11

ScoreIf your score is 2 or higher, then you may have a memory problem - You should get checked out by a doctor.

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12

Name* This field is requiredBy typing your name and submitting your data, you acknowledge agreement to the Terms and Condition found on the Modiin Neurology Clinic website (www.modiinneurology.com)

First Name

Last Name

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