Birmingham and Midland Memory Clinic

Everyone has occassional lapses in their memory, click yes to the following questions if this is happening on a regular basis:

1. Have you forgotten what you heard on the news yesterday?	Yes No
2. Do you mislay things around the house?	Yes No
3. Do you forget names of people and everyday things?	Yes No
4. Have you forgotten close family birthdays recently?	Yes No
5. Have you lost your way on a previously familiar route?	Yes No
6. Do you get muddled over the days of the week?	Yes No
7. Have friends or family commented your memory is getting worse?	Yes No
8. Has anyone in your family had a memory problem or suffered with dementia?	Yes No
9. Do you find that you need to make lists to remember things?	Yes No
10. Do you suffer with any of the following illnesses?
Heart problems	Yes No
Diabetes	Yes No
High blood pressure	Yes No
High Cholesterol	Yes No

BMI The Priory Hospital
Priory Road, Edgbaston
Birmingham B5 7UG

Tel: 0121 450 8928
Fax: 0121 455 0288