Attachment 1: Questions to be Cognitively Tested
Form Approved
OMB No. 0920-0222
Exp. Date: 01/31/2026
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Proposed Questions:
Five question module (2023 revision)
Intro1: The next few questions ask about difficulties in thinking or memory that can make a big difference in everyday activities. We want to know how these difficulties may have impacted you.
Q1. During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?
Yes
No [go to next module]
Don’t know [go to next module]
Refused [go to next module]
Q2. Are you worried about these difficulties with thinking or memory?
Yes
No
Don’t know
Refused
Q3. Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?
Yes
No
Don’t know
Refused
Q4. During the past 12 months, have your difficulties with thinking or memory interfered with day-to-day activities, such as managing medications, paying bills, or keeping track of appointments?
Yes
No
Don’t know
Refused
Q5. During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?
Yes
No
Don’t know
Refused
Additional questions
Q1. Over the past 12 months, how have your memory and thinking abilities compared with that of your peers (i.e., friends or acquaintances of a similar age)?
Better than
The same
Worse than
Don’t know
Refused
Q2. During the past 12 months, have you become concerned about your memory loss and thinking?
1. Yes
2. No
3. Don’t know
4. Refused
Six question module (pre-2023)
Intro2: The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.
1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?
Yes [Go to Q2]
No [Go to next module]
Don’t Know [Go to Q2]
Refused [Go to next module]
2. During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills?
Always
Usually
Sometimes
Rarely
Never
Don’t Know
Refused
3. As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities?
Always
Usually
Sometimes
Rarely [Go to Q5]
Never [Go to Q5]
Don’t Know[Go to Q5]
Refused [Go to Q5]
4. When you need help with these day-to-day activities, how often are you able to get the help that you need?
Always
Usually
Sometimes
Rarely
Never
Don’t Know
Refused
5. During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home?
Always
Usually
Sometimes
Rarely
Never
Don’t Know
Refused
6. Have you or anyone else discussed your confusion or memory loss with a health care professional?
Yes
No
Don’t Know
Refused
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Massey, Meredith (CDC/DDPHSS/NCHS/DRM) |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |