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Clinical
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Alzheimer's Quiz (Lundbeck)
Alzheimer's Quiz (Lundbeck)
I am taking this assessment for ...
Are you 18 or older?
Myself
My Spouse
A Sibling
A Parent
A Different Loved One
How long have you been experiencing memory problems?
Do you currently smoke at least 10 cigarettes daily?
Less than 2 weeks
1-6 Months
6-12 Months
1-2 Years
2-4 Years
More than 4 Years
Which of these bests describe your situation?
Do you want to quit smoking cigarettes?
Learning - recalling information, remembering events, getting lost, misplacing items Language - difficulty with speech, spelling errors, writing errors
Visuospatial - Impairment in face-object recognition, inability to operate simple implements or orient clothing to the body
Executive Functioning - Reasoning impaired judgment, problem solving, reasoning, poor understanding of safety risks, inability to manage finances, inability to plan complex or sequential activities
Orientation - Time relationships and geographical disorientation
Behavioral / Personality Changes - Agitation, social withdrawal, loss of initiative, decreased interests in previous activities related to home and hobbies
Do you live with anyone?
Have you tried to smoke smoking cigarettes before, but it did not work?
Yes - Spouse
Yes - Family
Yes - Friend
No – Alone
Would you have someone that could attend appointments with you and commute to Princeton?
Are you currently using any other methods to stop smoking cigarettes currently?
Yes
No
Possibly
Does your family have a history of memory problems?
Do you have any heart disease history?
Yes - Parents
Yes - Siblings
Yes - Grandparents
Yes - Uncles / Aunts
No
Do you or your family have a history of cancer?
Do you have any psychiatric history?
Yes - Parents
Yes - Siblings
Yes - Grandparents
Yes - Uncles / Aunts
No
Do you have any allergies (i.e., drugs, food, etc.)?
Yes - Drugs
Yes - Food
Yes - Both
No
Other
Do you use illicit drugs / marijuana or consume 2 or more alcoholic beverages per day?
Yes
No
Are you currently breastfeeding?
Yes
No
Not Applicable (ONLY IF CAN’T CREATE NEW SETS OF QUESTIONS FOR FEMALES)
Do you currently smoke or use other nicotine containing products?
Yes
No
Have you recently experienced any suicidal thoughts?
Yes
No
Are you on memory medications?
Yes
No
Not Sure
Please tell us about yourself.
Male
Female
Other
How old are you?
50-54
55-64
65-85
86-90
90-100+
Please enter your name.
Please enter your email address.
Please enter your phone number.
Time is Up!
Time's up
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Alzheimer's (Lundbeck) 2.0
