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.