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(1) Do you decide to do something in a few minutes’ time and then forget to do it? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(2) Do you fail to recognize a place you have visited before? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(3) Do you fail to do something you were supposed to do a few minutes later even though it is there in front of you, like taking a pill or turning off the kettle? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(4) Do you forget something that you were told a few minutes before? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(5) Do you forget appointments if you are not prompted by someone else or by a reminder such as a calendar or diary? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(6) Do you fail to recognize a character in a radio or television show from scene to scene? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(7) Do you forget to buy something you planned to buy, like a birthday card, even when you see the shop? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(8) Do you fail to recall things that have happened to you in the last few days? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(9) Do you repeat the same story to the same person on different occasions? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(10) Do you intend to take something with you, before leaving a room or going out, but minutes later leave it behind, even though it is there in front of you? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(11) Do you mislay something that you have just put down, like a magazine or glasses? |
| Very often | Quite often | Sometimes | Rarely | Never |
|
(12) Do you fail to mention or give something to a visitor that you were asked to pass on? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(13) Do you look at something without realising you have seen it moments before? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(14) If you tried to contact a friend or relative who was out, would you forget to try again later? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(15) Do you forget what you watched on television the previous day? |
| Very often | Quite often | Sometimes | Rarely | Never |
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(16) Do you forget to tell someone something you had meant to mention a few minutes ago? |
| Very often | Quite often | Sometimes | Rarely | Never |
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