Home
Clinic
- Bookings
- Testing
New Patients
- New patient intake form
Blog
Questionnaires
Health Topics
Recipes
About me
Contact

Alzheimer’s Assessment

Please complete the quiz below to assess your risk of developing or currently having Alzheimer’s disease. Note that this quiz is not intended to replace detailed clinical assessment and diagnosis.

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Loading

First Name

Last Name

Email

Does your loved one have memory loss?*

Yes

No

If so, is their memory worse than a few years ago?*

Yes

No

Do they repeat statements or stories in the same day?*

Yes

No

Have you had to take over tracking events or appointments, or does the patient forget appointments?*

Yes

No

Do they misplace items more than once a month?*

Yes

No

Do they suspect others of hiding, or stealing items when they cannot find them?*

Yes

No

Does your loved one frequently have trouble knowing the day, date, month, year, and time; or check the date more than once a day?*

Yes

No

Do they become disoriented in unfamiliar places?*

Yes

No

Do they become more confused when not at home or when traveling?*

Yes

No

Excluding physical limitations, do they have trouble handling money, such as tips or calculating change?*

Yes

No

Do they trouble paying bills or doing finances?*

Yes

No

Does your loved one have trouble remembering to take medicines or keeping track of medications taken?*

Yes

No

Do they difficulty driving; or are you concerned about their driving?*

Yes

No

Are they having trouble using appliances, such as the stove, phone, remote control, microwave?*

Yes

No

Excluding physical limitations, are they having difficulty completing home repair or housekeeping tasks?*

Yes

No

Excluding physical limitations, have they given up or cut down on hobbies such as golf, dancing, exercise or crafts?*

Yes

No

Are they getting lost in familiar surroundings, such as their own neighbourhood?*

Yes

No

Is their sense of direction failing?*

Yes

No

Do they have trouble finding words other than names?*

Yes

No

Do they confuse names of family members or friends?*

Yes

No

Do they have trouble recognizing familiar people?*

Yes

No

Your form has been submitted

Thank you for taking the Alzheimer's Assessment Questionnaire. You will be redirected to your results in a moment.

Server Side Error

We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.

If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.

TextStatus: undefined
HTTP Error: undefined

Processing you request

Error

Some error has occured.

Home
Clinic
New Patients
Blog
Questionnaires
Health Topics
Recipes
About me
Contact