Table 1: Items of the Checklist for Cognitive Blackouts (CCB).

Within the last six months how often did it happen to you that ...
(1) ... you wanted to get something from another room and when you
got there you had forgotten what it was that you went there for?
(2) ... you forgot to keep a date or an appointment or would have
forgotten them without being reminded about it beforehand
(e.g. by a calendar or by others)?
(3) ... you took a break from reading a book or a text and when
you returned to it you had serious difficulties in recalling
what you had read or picking up where you had left off?
(4) ... you had to think about what month it is?
(5) ... you had significant difficulties finding your way at a place
that was new to you (e.g. in a hotel or locating your car in a
big shopping center's parking lot)?