What is your age in years?

Do you have a diagnosis of Alzheimer's disease or another form of dementia?

Do you repeat questions about the events of the day?

Does you have trouble recalling conversations the next day?

Does you have trouble recalling conversations a few days later?

Has there been confusion while doing familiar things?

Have you become confused about financial matter (for example, paying bills multiple times?

Have you become confused regarding the day, month, or year?

Have you become lost or confused when driving or walking in a familiar place?

Have you seemed bewildered or confused in familiar places?

Have you become lost while traveling in an unfamiliar location?

Do you have difficulties adjusting to changes in your day-to-day routine?

Do you have trouble performing tasks that require many step (for example, balancing checkbook or cooking a meal)?

Are you unable to respond with a reasonable plan to problems at work or home, such as knowing what to do if the bathroom is flooded or the electricity goes out?

Are there pauses in your speech?

Are you often unable to find even common works or familiar names, so that you find it difficult to have a normal conversation?

Do you often forget what you wanted to say in the middle of a conversation?

Have there been any changes in personality (including mood and behavior)?

Has you been agitated?

Have your problems worsened steadily?

Please provide your contact information below. One of our staff members will contact you.