How are you feeling today?
Give us your name and your age.
Fill in the date and the time.
Look at the list on the page:
What were your grandparents’ names?
Think of ten species of trees.
(Where did you put down your phone?
Have you remembered your keys?)
What was the age of your cat?
Which is your favorite beer?
Who is the president now?
When did all hope disappear?
Enter your password or PIN.
What goes with spoon and with knife?
Whom have you named in your will?
Why have you wasted your life?
No one is saying you failed.
Some people veer from the norm.
Here is a plan for your care.
Sign at the end of the form.