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Dementia Survey

General Info

Birthday
Month
Day
Year
Gender
Male
Female
Prefer not to say
Other
Level of Education
Primary
Secondary
College/University
Higher Education
None
Family History of Dementia
Yes
No
History of Stroke, Head Injury, or Neurological Disorders
Yes
No

Cognitive Function

Memory loss (recent or long-term)
Difficulty finding words or communicating
Getting lost in familiar places
Difficulty with planning or problem-solving
Trouble understanding visual information (e.g., reading, recognizing faces)
Repeated questions or conversations
Living situation
Alone
With family
Assisted Living
Other
APOE ε4 status if available (optional)
I have the APOE ε4 allele
I do not have the APOE ε4 allele

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