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Memory Survey

Your brain is the most important part of your body.  It is the control center that allows you to think, feel, remember, move, digest food and even controls your heart.  It is paramount to check your brain’s functioning on a regular basis.  This is as important as your other vital signs, especially if you are over age 40.

 

This Memory Survey is intended to assess common memory concerns and track your awareness of your memory performance over time.  The survey only takes a few minutes.  This is your self-assessment.  Your results will be emailed to you.  Take it every month or as often as you like.  Vivolor® Therapeutics will provide a chart of your results over time. It is very important to know if your memory is worsening and this survey is one way to improve your awareness.   It can also be used to track changes in drugs or lifestyle.

 

This Memory Survey is FREE and you can take it as often as you want for the rest of your life. 

 

Memory Survey

For each statement, write the number corresponding to the frequency that best applies:
5 = Never
4 = Rarely
3 = Occasionally
2 = Somewhat Often
1= Very Often

Welcome to your Memory Survey

1. I have difficulty finding the right word
2. I forget acquaintances names
3. I forget names of people I know well
4. I lose my train of thought
5. I have difficulty understanding directions
6. I misplace objects
7. I enter a room and forget why I went there
8. I feel increasingly overwhelmed
9. My mental processing is slower than before
10. I forget details of conversations or things I’ve read
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