Memory Lapses I rarely forget things I occasionally forget things, and it affects my daily life I frequently forget things, and it affects my daily life I almost always forget things, and it is severely impacting my life None Concentration and Focus I can concentrate and stay focused without any issues I sometimes have trouble focusing but it is manageable I often struggle to concentrate, which disrupts my activities I almost always find it difficult to focus, and it is a significant problem None Mental Clarity My mind feels clear and sharp most of the time I occasionally experience a foggy mind, but it does not last long I frequently feel mentally foggy, sometimes/often impacting my life I almost always feel mentally foggy, severely impacting my life None Problem Solving Abilities I can solve problems and think critically without difficulty I sometimes struggle with problem solving, but I manage I often find it hard to solve problems and think critically I almost always struggle with problem solving, which is a major issue None Verbal Communication I can express myself clearly and find the right words easily I occasionally struggle to find the right words, but it is not frequent I frequently have trouble finding the right words, impacting conversations I almost always struggle with verbal communication, which is very problematic None Overall Cognitive Function I feel that my cognitive function is as good as it has always been I have noticed some minor changes in my cognitive function, affecting my daily life I have experienced significant changes in my cognitive function, affecting my daily life My cognitive function has declined considerably, severely impacting my life None 1 out of 2 Name Email Phone Time's up
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