Updated
Original VAYEMA symptom and impact self-check – not a validated scale
Memory gaps
Answer the symptom statements below to see which experiences and areas of daily life you report as most affected. These are original VAYEMA questions, not a validated diagnostic scale. No clinical severity or probability score is calculated.
Answers are processed only in this page by this assessment. They are not submitted, monitored or automatically saved. No name, email or account is required. Use a private device and clear your answers when finished.
For adults aged 18 and over. This self-check cannot diagnose or rule out a condition. Concerns about a child require an age-appropriate professional assessment.
Thinking about the past four weeks, how well does each statement describe your experience?
Additional context – not included in any questionnaire score
These are original VAYEMA questions, not a diagnostic instrument or a validated severity scale. They summarise the experiences you select and do not predict a diagnosis or future harm. Background condition information; this source does not endorse this self-check.
The first question is the nature and urgency of the change
A clinician needs to know whether the problem is new, sudden, progressive or limited to particular personal information. Difficulty recalling an old event is not the same presentation as becoming acutely confused today. The NHS memory-loss guidance advises seeking professional assessment rather than deciding the cause from general information.
Describe the change and its practical consequences as directly as possible. If someone is disoriented, injured or unable to remain safe, obtain appropriate urgent help rather than complete preparation first. A routine private appointment can be useful for planned assessment, but an online description of dissociation should never replace medical evaluation of an acute concern.
Describe what is missing without filling the gap
You might know that a period or piece of personal information is difficult to recall, or have learned about an event through another person. Record how you became aware of the difficulty. The clinician can distinguish these observations from an interpretation about why they occurred.
There is no need to guess what happened in order to complete a note. A partial account that clearly identifies uncertainty is more useful than a complete-sounding story assembled from suggestions. The MSD Manual overview describes the importance of careful assessment and distinguishing dissociative amnesia from other explanations of memory loss.
Explain the timeline and everyday effects
Approximate dates, changes in routine and examples of affected tasks can help a professional understand the pattern. You might have missed an appointment, become uncertain about a recent conversation or struggled with an important personal detail. The assessment should consider what has changed from your usual functioning rather than use one forgotten item as a diagnostic sign.
Include abilities that remain intact as well as difficulties. A clinician can use that information to decide what needs examination or further assessment. You do not need to test yourself repeatedly or document every moment. If attempts to record the problem increase distress or confusion, say so and ask what minimum information would be useful.
Medical history and substances must be discussed honestly
Relevant questions can include head injury, seizures, recent illness, medicines, alcohol and other substances. Sleep and other health changes may also affect recall. The presence of stress does not eliminate those possibilities. A clinician may recommend examination or targeted investigations when the history raises a specific concern.
Bring a medication list or relevant existing reports where available. Do not stop a prescription abruptly or use substances to see whether memory changes. If you cannot recall a detail, explain the uncertainty rather than provide a reassuring estimate. The goal is appropriate care, not a judgement about how well you remember medical information before being assessed.
Known stress and trauma are context, not proof of missing events
The American Psychiatric Association overview describes links between dissociative conditions and trauma. A clinician may therefore ask about experiences you know occurred. That is different from assuming that a memory gap proves an unknown event or from suggesting the content of what is missing.
You can discuss current distress while declining to speculate. A professional should distinguish what you remember, what others report and what remains uncertain. The worksheet does not request graphic details, separate identities or hidden memories. Support should not depend on finding a particular explanation that makes the account appear to fit a diagnosis.
Other mental-health symptoms may be relevant
A clinician may ask about depression, panic, detachment, trauma-related symptoms or other changes in awareness. Several difficulties can coexist, but one diagnosis should not automatically explain every aspect of memory. The assessment needs to consider the whole pattern and whether additional expertise is required.
Our detachment and unreality preparation page and depression assessment guide describe related questions. You do not need to complete them before attending. A few observations about the most important symptoms can be more helpful than collecting multiple scores and trying to interpret them without a clinician.
Information from others should be identified and handled carefully
A relative or existing clinician may provide useful observations, with appropriate agreement and attention to privacy. Their account is one source of information, not automatically a definitive explanation. A patient should have an opportunity to discuss concerns privately rather than feel required to accept a family’s account of the past as a condition of care.
Existing documents may clarify dates or practical facts without resolving every question about personal experience. Ask how information will be recorded, who can access it and how uncertainty is represented. Family support can separately address relatives’ worries without asking them to conduct an investigation or recover someone else’s memories.
Why this is not a memory-recovery or diagnostic test
A professional assessment may use appropriate examination, interviews or tests to answer particular questions. A short website worksheet cannot measure the accuracy of autobiographical recall, exclude neurological disease or establish dissociative amnesia. Different memory problems require different assessment methods, and a generic score would obscure that distinction.
These prompts are original and unscored. They do not provide a probability, severity label or memory-recovery exercise. Do not use repeated self-testing, guided imagery or online scripts to establish what happened during a gap. The value of the notes is in communicating observations to a qualified professional, not generating a story or obtaining a diagnosis from an automated result.
Ask what the assessment suggests and what remains uncertain
A useful conclusion explains the current understanding, any medical questions, suitable support and the need for further assessment. Ask what evidence supports the formulation and how other possibilities were considered. It is appropriate for a clinician to acknowledge uncertainty rather than offer a confident explanation unsupported by the available information.
The treatment guide describes care focused on safety, functioning and associated symptoms. A plan should identify the responsible professional, initial format and review point. It should not promise to restore every memory or make a particular disclosure the expected outcome of treatment.
Keep preparation private and seek direct help when needed
The tool does not send your entries to VAYEMA, interpret them or store them in a client record. Reviewing the notes displays your own words. Any download is a file you choose to retain and should keep private. Avoid unnecessary identifying details about other people and share clinical information only through an agreed appropriate channel.
You can contact the assessment team without completing a worksheet, or read the understanding guide for background. Coordination may support practical continuity where needed. Sudden memory changes, confusion or immediate danger require direct medical or emergency help, not a routine inquiry or an expectation that notes entered here are monitored.
Frequently asked questions about dissociative amnesia assessment
Can these prompts tell me why a memory is missing?
No. The worksheet is an unscored communication aid, not a diagnostic memory test. A clinician needs to consider medical, substance-related and psychological explanations. A gap does not identify its own cause, and the tool cannot determine whether a particular event occurred or why it is difficult to recall.
Should I write what I think probably happened?
Keep guesses separate from what you directly remember or know from another source. It is acceptable to leave a gap uncertain. A careful assessment should not require a complete account or encourage you to fill missing information with suggestions merely because they seem plausible or emotionally convincing.
Can a family member's account settle the diagnosis?
It may provide useful observations but does not replace the individual’s assessment or automatically establish the explanation. A clinician considers different sources and their limits, with appropriate consent and privacy. The person should have space to discuss uncertainty without pressure to accept one account of events.
Do incomplete childhood memories prove dissociative amnesia?
No. Ordinary autobiographical recall varies. A clinician considers the nature, extent, functional impact and other explanations of the difficulty. Missing detail alone does not establish a disorder or a hidden traumatic event, and an online worksheet cannot verify either conclusion.
Will the assessment necessarily involve methods to recover memories?
Not necessarily. It may focus on medical evaluation, current functioning and support. Ask about the purpose and limitations of any proposed method, including how suggestion is avoided. Care should not promise a particular recovered account or make complete recall the only acceptable outcome.
What should I do if memory loss is sudden or severe?
Seek appropriate medical attention promptly, using emergency services where indicated. New confusion, injury, loss of consciousness or other acute symptoms should not be assumed to be dissociative. Do not delay direct help while completing notes or waiting for a routine private appointment.
Resources and references
[1] NHS: memory loss and appropriate medical review
[2] MSD Manual Professional: dissociative amnesia assessment and uncertainty
[3] American Psychiatric Association: dissociative disorders and clinical context