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?