Cognition / Memory Questionnaire Cognition / Memory Questionnaire This quiz helps you assess your cognitive function and helps determine if you could benefit from nootropic (cognitive-enhancing) supplements. Note: This questionnaire is completely confidential and your answers are for you alone. Scores will be provided to you immediately upon submission and results will NOT be stored or used in any other capacity. If you enter your email (optional) in the designated place, you will automatically receive your completed questionnaire via email. Again, confidentiality means that email is not stored or viewed by anyone else. Rate each statement on a scale of 0 – 3, with: 0 = Never 1 = Rarely 2 = Occasionally 3 = Regularly1. Enter a room and forget what you intended to do?*01232. You can’t remember a phone number and must write it down.*01233. You forget where you put something (misplaced glasses, keys)*01234. Find it difficult to follow a movie plot?*01235. Recite the same story to the same person more than once.*01236. Forget what you’ve read. Need to re-read for clarity.*01237. Have gotten lost, confused, in a place where you’ve been before.*01238. Can “word-search.” Have to hunt for a word that you should know.*01239. Are forgetful of recent events, e.g. what you did yesterday.*012310. Often forget to take the things you need when leaving the house.*012311. Have to be reminded of things – appointments, promises, etc.*012312. Have to look in several places to find common household items.*012313. Forget where you put some object. Have to search to find it.*012314. Ask the same person the same question twice.*012315. Forget details of routine procedures.*012316. Lose track of time.*012317. Forget or miss appointments.*012318. Have to ask a listener to remind you what you are talking about.*012319. Find it hard to remember a new acquaintance’s name.*012320. Check and recheck things like the oven, iron, if a light is on, etc.*012321. Find it difficult to learn a new skill or game.*0123First Name (Optional): First name is completely optional and has no impact on receiving your results on the next page. It just adds a personal touch is all. Email Address (Optional): Entering your Email Address is completely optional and, again, has no impact on receiving your results on the next page. If you wish to receive a copy of your results via email, feel free to enter your best email address.Total ScoreDisclaimer: This questionnaire is not intended to be used to diagnose any disease or as a basis for prescribing for any disease. It is solely for self-knowledge. Δ
