Questions:

1. Overall in the last 30 days overall how much difficulty did [name of the person/you] have remembering things?
2. In the last 30 days how much difficulty did [name of person/you] have with mental arithmetic?
3. In the last 30 days, how much difficulty did [name of person] have in learning a new task (for example, learning how to get to a new place, learning a new game, learning a new recipe etc.)?

Response categories:

1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/Cannot Do

1. [Xanta] remembers every detail of past events including names of people, places, streets and dates in chronological order. She is a history teacher and can lecture for 2 hours without looking at her notes. She is very quick with doing complex sums in her head.
   
   
2. [Rob] is very quick to learn new skills at his work. He can pay attention to the task at hand for long uninterrupted periods of time. He can remember names of people, addresses, phone numbers and such details that go back several years.***
   
   
3. [Sandra] never needs to write anything down and remembers what she has to do. Over the last month, however, she has been very worried and anxious about the health of one of her children and has started to forget phone numbers and items from the grocery store. She enjoys learning new things and continues to be able to do this. Very occasionally she struggles with adding and dividing large numbers in her head.
   
   
4. [Malcolm] can concentrate while watching TV, reading a magazine or playing a game of cards or chess. He can learn new variations in these games with small effort. Once a week he forgets where his keys or glasses are, but finds them within five minutes.***
   
   
5. [Alfred] can remember details of events that have taken place or names of people he has met many years ago. He can do everyday calculations in his mind. During periods of anxiety lasting 2 to 3 hours once a month, he becomes confused and cannot think very clearly.
   
   
6. [Johanna] can pay attention to the task she is performing for periods of up to one hour, and has no trouble returning to work after being distracted by conversation with her colleagues. She can remember names of people she meets often, their addresses and important numbers, but occasionally has to remind herself of the names of people she went to school with 10 years ago. She can do sums in her head very quickly.
   
   
7. [Marjorie] had a car accident a year ago and was in a state of coma for several months. She is conscious now but only remembers events that have happened since the accident. She does not remember anything about her past, not even her family or friends. Though she can add and subtract numbers in her head, multiplication and division is a problem.
   
   
8. [Tom] finds it difficult to concentrate on reading newspaper articles or watching television programmes for more than 30 minutes. He is forgetful and once a week or so, he misplaces important things, such as keys or money, but is able to find them eventually. He can count change correctly while shopping but adding up prices of several things in his head is a problem.
   
   
9. [Sue] can find her way around the neighbourhood and know where her own belongings are kept, but struggles to remember how to get to a place she has only visited once or twice. She is keen to learn new recipies but finds that she often makes mistakes and has to reread several times before she is able to do them properly.***
   
   
10. [Theo] cannot concentrate for more than 15 minutes and has difficulty paying attention to what is being said to him. Whenever he starts a task, he never manages to finish it and often forgets what he was doing. He is able to learn the names of people he meets but cannot be trusted to follow directions to a store by himself.***
    
    
11. [Juliana] is easily distracted and within 10 minutes of beginning a task her attention drifts to something else. She can remember important facts when she tries, but four or five times a week finds that she has to struggle to recollect what people have said or events that have taken place in the last month. Though adding and subtracting numbers in her head is not a problem, she makes mistakes if she has to multiply or divide numbers in her head.
    
    
12. [Biko] likes to tell people about his his travels to countries abroad and his experiences. He remembers past events but not what he did the previous week or what he had for lunch that same day. He finds it impossible to count the change correctly when he goes to a shop.
    
    
13. [Christian] is very forgetful and often loses his way around places that are not very familiar. He needs to be prompted about names of close relatives and loses important things such as keys and money every day. He has to make notes to remind himself to do even very important tasks. He cannot identify money when shown and cannot count coins.
    
    
14. [Anthea] lives with her sister. She gets quite confused and disoriented once or twice a day and does not remember where she is or who her sister is. She does not remember the time of day and has been found three times during the last month wandering in the middle of the night thinking it was daytime. During these periods she notices that she cannot count numbers in her head.
    
    
15. [Peter] does not recognize even close relatives and gets lost when he leaves the house unaccompanied. Even when prompted, he shows no recollection of events or recognition of relatives. It is impossible for him to acquire any new knowledge as even simple instructions leave him confused.***
    

*** Included in the final World Health Survey instrument in 2002.