Personalized Cognitive Health Assessments
Instructions: Some people feel that things aren’t as good as they were in the past, whereas some people feel that things are better now than they were in the past. This survey asks how people feel about the world today, relative to the past.
Please compare life now to what you believe life was like in the past 40 years ago using this scale and spread out your numbers from 1 (Strongly Disagree) to 5 (Strongly Agree)
1
Strongly
Disagree
2
Somewhat
Disagree
3
Neither Agree
nor Disagree
4
Somewhat
Agree
5
Strongly
Agree
Instructions: Some people feel that things will become worse in the future than they are today, whereas some people feel that things will be better in the future than they are today. This survey asks how people feel about the world in the future, relative to today.
Please compare life now to what you believe life will be like in the future 40 years from now using this scale and spread out your numbers from 1 (Strongly Disagree) to 5 (Strongly Agree)
1
Strongly
Disagree
2
Somewhat
Disagree
3
Neither Agree
nor Disagree
4
Somewhat
Agree
5
Strongly
Agree
Instructions: One a scale of 1 = not difficult at all to 4 = very difficult, please answer how hard it is for you to pay for basics like:
Directions: Different people use their memory in different ways in their everyday lives. For example, some people make shopping lists, whereas others do not. Some people are good at remembering names, whereas others are not.
In this questionnaire, we would like you to tell us how you use your memory and how you feel about it. There are no right or wrong answers to these questions because people are different. Please take your time and answer each of these questions to the best of your ability.
Directions: Different people use their memory in different ways in their everyday lives. For example, some people make shopping lists, whereas others do not. Some people are good at remembering names, whereas others are not.
Each question is followed by five choices. Draw a circle around the answer that best fits your
situation. Choose only one for each statement.
Some of the questions ask your opinion about memory-related statements, for example:
My memory will get worse as a. agree strongly I get older.
a. agree strongly
b. agree
c. undecided
d. disagree
e. disagree strongly
Memory Confidence
In this questionnaire there are statements about your memory. Read each statement and provide the answer that is right for you by following the directions and practicing with the example below.
First of all you will be asked to agree or disagree with the following practice statement.
If you do not agree with the statement, circle NO.
If you agree with the statement, circle YES.
If you agree and circle YES, we would like to know how confident you are of your answer. To indicate your confidence, circle the number that shows the percent (amount) of your confidence.
Practice or Sample Statement:
"If I wanted to, I could memorize all of my friends' phone numbers."
NO YES 10% 20 30 40 50 60 70 80 90 100%
If you circled NO, go on to the next question.
If you circled YES, mark the number indicating how confident you are of your answer.
For example, if you are completely sure you could remember all of your friends' phone numbers, circle 100%. Or you may be less sure of your ability. If you are 50% sure, circle 50. If you are less certain, you might circle 20 (for 20% sure) or 30 (for 30% sure).
There are no right or wrong answers. We are interested in what you think about your memory today.
Please go to the next page and provide the answer that is right for you by following the same directions:
If you do not agree with the statement, circle NO, and go on to the next question.
If you agree with the statement, circle YES.
If you agree and circle YES, we would like to know how confident you are of your answer. To indicate your confidence, circle the number that shows the percent (amount) of your confidence.
Mood Questionnaire
Depressive symptoms were measured with the short version of the Geriatric Depression Scale. This 15-item instrument has a YES/NO response format. Scores range from 0 to 15, with a score ≥ 5 indicating depression.
Geriatric Depression Scale (short form)
1 Tools may be copied without permission
Instructions: Circle the answer that best describes how you felt over the past week.
Total Score
Geriatric Depression Scale (GDS)
Scoring Instructions
Instructions: Score 1 point for each bolded answer. A score of 5 or more suggests depression.
A score of > 5 suggests depression Total Score