SUBJECTIVE MEMORY QUESTIONNAIRE

Memory changes are a natural part of growing older. How aware are you of your own memory changes? To find out complete the subjective memory questionnaire below.

After you have answered all of the questions, click on "Calculate your score", and you will receive your score and an explaination of what it means. You will also receive an email copy of your score.

Name:
Email:
POOR
GOOD
EXCELLENT
Overall Memory
1
2
3
4
5
6
7
Rate your overall memory
 
 
How often are these a problem for you?
 
ALWAYS
SOMETIMES
NEVER
Remembering Names
1
2
3
4
5
6
7
Names of people
 
 
Names of places (restaurants, movie theater, store,etc.)
 
 
Titles (movies, books, etc.)
 
 
 
ALWAYS
SOMETIMES
NEVER
Remembering What
1
2
3
4
5
6
7
Forgetting to complete one of my errands (e.g. pick up or drop off an item at a store or business)
 
 
Performing household tasks
 
 
Forgetting why I walked into a room
 
 

Beginning something and forgetting what I was doing

 
 
Phone numbers I use often
 
 
Phone numbers just checked
 
 
Personal information when filling out forms
 
 
 
ALWAYS
SOMETIMES
NEVER
Remembering Where
1
2
3
4
5
6
7

Forgetting where I put my things (e.g. eyeglasses, keys)

 
 
Forgetting where I parked my car
 
 
Directions to places I frequent
 
 
 
ALWAYS
SOMETIMES
NEVER
Remembering When
1
2
3
4
5
6
7
Forgetting appointments
 
 
Forgetting special dates (e.g. birthdays, anniversaries)
 
 
Forgetting to take medications
 
 
 
ALWAYS
SOMETIMES
NEVER
Remembering In Conversations
1
2
3
4
5
6
7
Forgetting whether I told someone something
 
 
Forgetting whether they told me something
 
 
Losing my train of thought in a conversation
 
 
Finding the right word
 
 
 
ALWAYS
SOMETIMES
NEVER
Remembering What I've Read In A Novel
1
2
3
4
5
6
7

Opening chapters once I've finished the book
 
 
Three or four chapters before the one I am reading
 
 

The chapter before the one I am reading
 
 

Paragraph just before the one I am reading now
 
 
Sentence before the one I am reading
 
 
 
ALWAYS
SOMETIMES
NEVER
Remembering Things Which Occurred...
1
2
3
4
5
6
7
Last week
 
 
Last month
 
 
Several months ago
 
 
Last couple of years
 
 
Several years ago
 
 
This memory survey was adapted from Dr. Gary Small's "The Memory Bible."
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