Trials for Clinical Research

Who are you taking this assessment for?Deselect Answer

Myself

My Spouse

A Sibling

A Parent

A Different Loved One

1 out of 11

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

2 out of 11

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

3 out of 11

Do you live with anyone?Deselect Answer

Yes - Spouse

Yes - Family

Yes - Friend

No - Alone

4 out of 11

Would you have someone that could attend appointments with you?Deselect Answer

Yes

Possibly

5 out of 11

Does your family have a history of memory problems?Deselect Answer

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?Deselect Answer

Yes

7 out of 11

Are you on memory medications?Deselect Answer

Yes

Not Sure

8 out of 11

Please tell us about yourself.Deselect Answer

Male

Female

9 out of 11

How old are you?Deselect Answer

18-49

50-54

55-64

65-85

86-90

90-100+

10 out of 11

How soon are you looking to take care of your memory problems?Deselect Answer

Right now

As soon as possible

This week

This month

11 out of 11

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