Brain Health Survey

GENERAL INFORMATION

Name*

Date*

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?

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?

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Comments

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Brain Healthy Survey

GENERAL INFORMATION

QUESTIONNAIRE