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Who are you taking this assessment for?
A Different Loved One
1 out of 11
How long have you been experiencing memory problems?
Less than 2 weeks
More than 4 Years
2 out of 11
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
3 out of 11
Do you live with anyone?
Yes - Spouse
Yes - Family
Yes - Friend
No - Alone
4 out of 11
Would you have someone that could attend appointments with you?
5 out of 11
Does your family have a history of memory problems?
Yes - Parents
Yes - Grandparents
Yes - Uncles / Aunts
6 out of 11
Do you ever get frustrated or agitated when you can’t remember something or find an item?
7 out of 11
Are you on memory medications?
8 out of 11
Please tell us about yourself.
9 out of 11
How old are you?
10 out of 11
How soon are you looking to take care of your memory problems?
As soon as possible
11 out of 11
Please enter your name.
Please enter your email address.
Please enter your phone number.
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