| Question: | Yes | No | Don’t Know | Not Answered | |
1. | Does memory loss happen to all people as they get older? | ⃝ Yes | ⃝ No | ⃝ Don’t Know | ⃝ Not Answered | |
2. | Is forgetting who your family members are a normal part getting old? | ⃝ Yes | ⃝ No | ⃝ Don’t Know | ⃝ Not Answered | |
3. | Is forgetting the names of objects a normal part of getting old? | ⃝ Yes | ⃝ No | ⃝ Don’t Know | ⃝ Not Answered | |
4. | Is having trouble with speaking or understanding a normal part of getting old? | ⃝ Yes | ⃝ No | ⃝ Don’t Know | ⃝ Not Answered | |
5. | These symptoms form part of a medical condition, what would you call this medical condition? | |||||
6. | Do you know what dementia is? | ⃝ Yes | ⃝ No | ⃝ Don’t Know | ⃝ Not Answered | |
7. | If yes, What is dementia? | |||||