How I Feel About My Memory
Name: _______________________________________ Date: ______________________
Below are statements about feelings that people may have about their memory. Read each
statement and think about your feelings over the past two weeks. Then, check the box next to
the response that best describes how much you agree or disagree.
1. I am generally pleased with my memory ability.
Strongly Agree Agree Undecided Disagree Strongly Disagree
2. There is something seriously wrong with my memory.
Strongly Agree Agree Undecided Disagree Strongly Disagree
3. If something is important, I will probably remember it.
Strongly Agree Agree Undecided Disagree Strongly Disagree
4. When I forget something, I fear that I may have a serious memory problem, like Alzheimer’s
disease.
Strongly Agree Agree Undecided Disagree Strongly Disagree
5. My memory is worse than most other people my age.
Strongly Agree Agree Undecided Disagree Strongly Disagree
6. I have confidence in my ability to remember things.
Strongly Agree Agree Undecided Disagree Strongly Disagree
7. I feel unhappy when I think about my memory ability.
Strongly Agree Agree Undecided Disagree Strongly Disagree
8. I worry that others will notice that my memory is not very good.
Strongly Agree Agree Undecided Disagree Strongly Disagree
9. When I have trouble remembering something, I’m not too hard on myself.
Strongly Agree Agree Undecided Disagree Strongly Disagree
Please turn page over to complete the questionnaire.
10. I am concerned about my memory.
Strongly Agree Agree Undecided Disagree Strongly Disagree
11. My memory is really going downhill lately.
Strongly Agree Agree Undecided Disagree Strongly Disagree
12. I am generally satisfied with my memory ability.
Strongly Agree Agree Undecided Disagree Strongly Disagree
13. I don’t get upset when I have trouble remembering something.
Strongly Agree Agree Undecided Disagree Strongly Disagree
14. I worry that I will forget something important.
Strongly Agree Agree Undecided Disagree Strongly Disagree
15. I am embarrassed about my memory ability.
Strongly Agree Agree Undecided Disagree Strongly Disagree
16. I get annoyed or irritated with myself when I am forgetful.
Strongly Agree Agree Undecided Disagree Strongly Disagree
17. My memory is good for my age.
Strongly Agree Agree Undecided Disagree Strongly Disagree
18. I worry about my memory ability.
Strongly Agree Agree Undecided Disagree Strongly Disagree
Multifactorial Memory Questionnaire: Satisfaction Scale (formerly Contentment Scale)
© Baycrest Centre for Geriatric Care 2002, 2016
Memory Mistakes
Name: _______________________________________ Date: ______________________
Below is a list of common memory mistakes that people make. Decide how often you have done
each one in the last two weeks. Then, check the box next to the appropriate response.
1. Forget to pay a bill on time.
All the Time Often Sometimes Rarely Never
2. Misplace something you use daily, like your keys or glasses.
All the Time Often Sometimes Rarely Never
3. Have trouble remembering a telephone number you just looked up.
All the Time Often Sometimes Rarely Never
4. Not recall the name of someone you just met.
All the Time Often Sometimes Rarely Never
5. Leave something behind when you meant to bring it with you.
All the Time Often Sometimes Rarely Never
6. Forget an appointment.
All the Time Often Sometimes Rarely Never
7. Forget what you were just about to do; for example, walk into a room and forget what you
went there to do.
All the Time Often Sometimes Rarely Never
8. Forget to run an errand.
All the Time Often Sometimes Rarely Never
9. In conversation, have difficulty coming up with a specific word that you want.
All the Time Often Sometimes Rarely Never
Please turn page over to complete the questionnaire.
10. Have trouble remembering details from a newspaper or magazine article you read earlier that
day.
All the Time Often Sometimes Rarely Never
11. Forget to take medication.
All the Time Often Sometimes Rarely Never
12. Not recall the name of someone you have known for some time.
All the Time Often Sometimes Rarely Never
13. Forget to pass on a message.
All the Time Often Sometimes Rarely Never
14. Forget what you were going to say in conversation.
All the Time Often Sometimes Rarely Never
15. Forget a birthday or anniversary that you used to know well.
All the Time Often Sometimes Rarely Never
16. Forget a telephone number you use frequently.
All the Time Often Sometimes Rarely Never
17. Retell a story or joke to the same person because you forgot you already told him or her.
All the Time Often Sometimes Rarely Never
18. Misplace something that you put away a few days ago.
All the Time Often Sometimes Rarely Never
19. Forget to buy something you intended to buy.
All the Time Often Sometimes Rarely Never
20. Forget details about a recent conversation.
All the Time Often Sometimes Rarely Never
Multifactorial Memory Questionnaire: Ability Scale
© Baycrest Centre for Geriatric Care 2002, 2016
Use of Memory Strategies
Name: _______________________________________ Date: ______________________
People often use different tricks or strategies to help them remember things. Several strategies
are listed below. Decide how often you used each one in the last two weeks. Then, check the
box next to the appropriate response.
1. Use a timer or alarm to remind you when to do something.
All the Time Often Sometimes Rarely Never
2. Ask someone to help you remember something or to remind you to do something.
All the Time Often Sometimes Rarely Never
3. Create a rhyme out of what you want to remember.
All the Time Often Sometimes Rarely Never
4. In your mind, create an image of something you want to remember, like a name and face.
All the Time Often Sometimes Rarely Never
5. Write things on a calendar, such as appointments or things you need to do.
All the Time Often Sometimes Rarely Never
6. Go through the alphabet one letter at a time to see if it sparks a memory for a name or word.
All the Time Often Sometimes Rarely Never
7. Organize information you want to remember; for example, organize your grocery list
according to food groups.
All the Time Often Sometimes Rarely Never
8. Say something out loud in order to remember it, such as a phone number you just looked up.
All the Time Often Sometimes Rarely Never
9. Use a routine to remember important things, like checking that you have your wallet and keys
when you leave home.
All the Time Often Sometimes Rarely Never
Please turn page over to complete the questionnaire.
10. Make a list, such as a grocery list or a list of things to do.
All the Time Often Sometimes Rarely Never
11. Mentally elaborate on something you want to remember; for example, focus on a lot of the
details.
All the Time Often Sometimes Rarely Never
12. Put something in a prominent place to remind you to do something, like putting your umbrella
by the front door so you will remember to take it with you.
All the Time Often Sometimes Rarely Never
13. Repeat something to yourself at increasingly longer and longer intervals so you will remember
it.
All the Time Often Sometimes Rarely Never
14. Create a story to link together information you want to remember.
All the Time Often Sometimes Rarely Never
15. Write down in a notebook things that you want to remember.
All the Time Often Sometimes Rarely Never
16. Create an acronym out of the first letters in a list of things to remember, such as carrots,
apples, and bread (cab).
All the Time Often Sometimes Rarely Never
17. Intentionally concentrate hard on something so that you will remember it.
All the Time Often Sometimes Rarely Never
18. Write a note or reminder for yourself (other than on a calendar or in a notebook).
All the Time Often Sometimes Rarely Never
19. Mentally retrace your steps in order to remember something, such as the location of a
misplaced item.
All the Time Often Sometimes Rarely Never
Multifactorial Memory Questionnaire: Strategy Scale
© Baycrest Centre for Geriatric Care 2002, 2016
