Alzheimer's Quiz (Lundbeck) – Trials for Clinical Research

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.