Pre-Screening Memory Questionnaire Name * First Last * Last Email * Home Phone Number * Mobile Phone Number What is the best time to contact you Morning Afternoon Evening OtherOther What is the best way to contact you Phone Email Text OtherOther I am interested in information for: Myself Family Member Friend OtherOther What is the birth year of the candidate: Have you noticed a decline in memory function Yes, decline over last 6 months Yes, more than 6 months decline No Not Sure OtherOther Have you talked to a doctor about memory problems Yes** No Not Sure OtherOther If you answered "yes" please check all exams completed: Memory assessments Imaging tests (MRI/PET scans) Blood tests No test done yet OtherOther Have you been diagnosed with a memory disorder Yes No OtherOther Are you taking any memory related medications? Yes No Not Sure OtherOther In addition to a study participant, our studies involve having a caregiver, friend or family member attend study visits with the participant for the duration of a study. Is there someone you think could attend visits with the participant? Yes No Not Sure OtherOther Is there anything else you would like us to know as we review this questionnaire? By selecting this checkbox, I consent to receiving text messages from The Alzheimer's Disease Research Center. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. Message frequency varies per user. Text HELP for help or call us at 518-426-0575. Reply STOP to unsubscribe. Please refer to our Privacy Policy and Terms and Conditions. * Yes Privacy Policy, Terms and Conditions Please check the box: If you are human, leave this field blank.
