Skip to main content

Memory Screening Questionnaire

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
5 Quick Questions
2. Do they have a current diagnosis of dementia or memory impairment?
3a. Have they had a memory screening before?
4. Reason for this screening:
Check all that apply.
5. Have you seen any of these changes?
Check all that apply.


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.



Give us a call at 703-204-4664 or email