Background and Objectives: Prior research has demonstrated a significant correlation between hearing loss and dementia; nevertheless, these two disorders have been addressed independently. This study proposes a questionnaire to simultaneously assess auditory and cognitive functions in older adults. As an inaugural pilot investigation, the current study aimed to engineer items for specific facets of cognitive function. Subjects and Methods: A systematic review of articles from six databases identified seven self-report questionnaires (211 items) for cognitive impairment and 31 cognitive items for screening older adults. Forty individuals aged 60 years or older were categorized into four groups based on their auditory and cognitive status using the pure-tone average (PTA) and Cognitive Impairment Screening Test (CIST), respectively. Each group completed the Cognitive Impairment Screening for Elderly (CISE). The internal consistency of the CISE was examined, and principal component and factor analyses were performed. Results: The four groups exhibited strikingly distinct PTA and CIST scores. The CISE demonstrated satisfactory internal consistency (α=0.94). Subsequently, Item 16 was excluded owing to inadequate fit, and the remaining 30 items were grouped by factor analysis into four categories: 10 pertaining to daily activities associated with memory loss, 8 concerning emotional alterations or stress, 7 associated with reduced social interaction and cognitive confusion, and 5 related to language usage difficulties. To comprehensively examine the individual factors, 7 representative items with factor loadings exceeding 0.70 were considered to represent these factors. Conclusions This study validated 30 items for the cognition section, from which 7 representative items were selected. Further development is warranted to create a single integrated questionnaire that incorporates items from the auditory section for effective diagnosis and treatment in future clinical settings.