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Who are you taking this assessment for?
A Different Loved One
How long have you been experiencing memory problems?
Less than 2 weeks
More than 4 Years
Which of these best describe your situation?
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?
Yes - Spouse
Yes - Family
Yes - Friend
No - Alone
Would you have someone that could attend appointments with you?
Does your family have a history of memory problems?
Yes - Parents
Yes - Grandparents
Yes - Uncles / Aunts
Do you ever get frustrated or agitated when you can’t remember something or find an item?
Are you on memory medications?
Please tell us about yourself.
How old are you?
How soon are you looking to take care of your memory problems?
As soon as possible
Please enter your name.
Please enter your email address.
Please enter your phone number.
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