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Beverly, MA
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Lawrence, MA
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Methuen, MA
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Portsmouth, NH (Borthwick Ave)
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Portsmouth, NH (Corporate Dr)
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Brain Health Survey
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Brain Health Survey
Brain Healthy Survey
Please fill out our survey to help us better understand the needs in our community.
GENERAL INFORMATION
Name
*
Date
*
Month
Day
Year
Age
*
Sex
*
Male
Female
Work Status
*
Employed
Retired
Insurance
*
Private
Medicare
None
Secondary Insurance Name (Optional)
QUESTIONNAIRE
1) If you could have a baseline test of where your memory is today, with the option of sharing the results with your Physician, would you be interested?
*
Yes
No
2) Would you be interested in services that could help with better memory & quality of life as you age?
*
Yes
No
3) If yes, what would you be most interested in?
Genetic Risk Profiling for family members.
Basic Screening of Memory online or in person.
Tests for memory, mood and functioning.
Assessments for Care Provider or Spouse at the same time (It has been proven information gathered from a care provider can help in the treatment of the patient).
4) If the above (2 & 3) were covered by insurance how likely would you be to seek out these services?
*
Highly Likely
Mildly Interested
Not Interested
5) If the above (2 & 3) were NOT covered by insurance how likely would you be to seek out these services?
*
Highly Likely
Mildly Interested
Not Interested
6) Would you be interested in any of the following?
Evening Lecture Series
Depression/Anxiety Counseling
Music Therapy
Memory Training Coaching
Memory Therapy, Interactive Sessions
Exercise Coaching
Meditation Training
Massage for Relaxation
Nutritional Counseling
Acupuncture for Relaxation
Supportive Training for New Technology Devices
Caregiver (Person Caring for Patient) Support Group
7) If the above were not covered by Insurance would you still be interested?
*
Yes
No
8) Would you be interested in a FREE Memory Loss & Dementia Lending Library?
*
Yes
No
9) Would you be interested in a store that provided books, CD’s, workbooks, brain games & trainings specifically for memory issues?
*
Yes
No
10) Would you be interested in participating in a research study?
*
Yes
No
11) Would you be interested in a FREE Memory Screening?
*
Yes
No
If you answered yes to questions 10 or 11, please enter your preferred method of contact below.
12) What is your preferred method of contact?
Phone
Email
Phone
Email
Enter Email
Confirm Email
Preferred days and times to reach you
What research studies are you interested in?
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
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Beverly, MA
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Methuen, MA
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Portsmouth, NH
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