Memory Screening Questionnaire : Contact : About Us : Insight Memory Care Center

A memory screening is a simple and safe evaluation tool that checks memory and other thinking skills. The questions below will help us better prepare for your screening to provide you resources and best meet your needs.

Contact Information

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Contact Name

Phone

5 Quick Questions

1. Individual who would receive the screening:

2. Do they have a current diagnosis of dementia or memory impairment?

3a. Have they had a memory screening before?

3b. If yes, when was the last screening?

4. Reason for this screening:

Check all that apply.

Noticing changes at home.
Want to see if there are changes since the last screening.
A doctor has recommended it.
Looking for information to bring to a neurologist.

5. Have you seen any of these changes?

Check all that apply.

Becoming more forgetful.
Trouble concentrating.
Difficulty performing familiar tasks.
Trouble recalling words or names in conversation.
Forget where I am or where I am going.
Misplacing things more often.
Family or friends have noticed repeated questions or saying the same thing over and over.
Become lost when walking or driving.
Changes in mood, behavior, personality, or a desire to do things.

Memory screenings are a helpful tool to check a person's memory, other thinking skills, and can indicate if someone might benefit from a more complete medical visit. However, I understand that a memory screening is not used to diagnose any particular illness and does not replace consultation with a qualified physician or healthcare professional.