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Trials
for
Clinical
Research
Trials
for
Clinical
Research
Who are you taking this assessment for?
Deselect Answer
Myself
My Spouse
A Sibling
A Parent
A Different Loved One
How long have you been experiencing memory problems?
Deselect Answer
Less than 2 weeks
1-6 Months
6-12 Months
1-2 Years
2-4 Years
More than 4 Years
Which of these best describe your situation?
Deselect Answer
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?
Deselect Answer
Yes - Spouse
Yes - Family
Yes - Friend
No - Alone
Would you have someone that could attend appointments with you?
Deselect Answer
Yes
No
Possibly
Does your family have a history of memory problems?
Deselect Answer
Yes - Parents
Yes - Grandparents
Yes - Uncles / Aunts
No
Do you ever get frustrated or agitated when you can’t remember something or find an item?
Deselect Answer
Yes
No
Are you on memory medications?
Deselect Answer
Yes
No
Not Sure
Please tell us about yourself.
Deselect Answer
Male
Female
How old are you?
Deselect Answer
18-49
50-54
55-64
65-85
86-90
90-100+
How soon are you looking to take care of your memory problems?
Deselect Answer
Right now
As soon as possible
This week
This month
Please enter your name.
Please enter your email address.
Please enter your phone number.
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Time's up
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