Dementia risk factor assessment
Section 1: Your contact details
Just so we can follow up
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
What is your sex?
M
F
Other
What is your date of birth?
-
Month
-
Day
Year
Date
Back
Next
Section 2: Genetic
Has any first degree relative (parents and siblings) ever been diagnosed with Alzheimer's diseases?
Yes
No
Don't know
Has any first degree relative (parents and siblings) ever been diagnosed with Alzheimer's diseases?
Yes
No
Don't know
Has any directly related aunt or uncle ever been diagnosed with Alzheimer's disease?
Yes
No
Don't know
Do you know if you are an ApoE4 carrier?
Yes
No
Don't know
Have you ever completed a genetic health screening (e.g. 23 and me) that has flagged an increased risk of Alzheimer's Disease or any other dementia?
Yes
No
Don't know
Back
Next
Section 3: Vascular
Have you ever been diagnosed by a doctor with hypertension (high blood pressure, above 120/80)?
Yes
No
Don't know
Have you been prescribed any blood pressure medication?
Yes
No
Don't know
Have you ever been told that you have high cholesterol?
Yes
No
Don't know
Have you been prescribed any medication to lower cholesterol, such as a statin?
Yes
No
Don't know
Have you ever been diagnosed with a stroke or mini-stroke?
Yes
No
Don't know
Has your doctor ever recommended therapy with aspirin, Xarelto, warfarin or any other blood-thinning medication?
Yes
No
Don't know
Have you ever been diagnosed with diabetes (mellitus, type II)?
Yes
No
Don't know
If yes, is it under control with fasting plasma glucose < 100mg/dL?
Yes
No
Don't know
Have you ever been diagnosed with hyperhomocysteinemia?
Yes
No
Don't know
Back
Next
Section 4: Lifestyle
What is your height and height?
Do you or have you ever smoked?
Never smoked
Quit > 12 months ago
Quit less than 12 months ago
Currently smoking (any frequency)
Have you ever sustained a significant head injury and have been diagnosed with concussion?
Yes
No
Don't know
Do you or did you regularly engage in sports that subject you to impact to your head, such as Football or Boxing?
Yes
No
Don't know
Have you had significant exposure (e.g. through agricultural work) to pesticides, fumigants, fertilizers, or defoliants?
Yes
No
Don't know
Please provide details of any potential exposure
How long did you spend at each of the following levels of education (please put 0 if you haven't completed it)?
Number of years spent
Primary School
High School
College
Postgraduate
Do you have a hearing impairment?
Yes, since childhood
Yes, but only since adulthood
No
How often do you do cardiovascular exercise (running, cycling, swimming) per week?
At least twice per week
Once per week
Less than once per week
What systolic heart rate do you generally reach during cardiovascular exercise? (if known)
How often do you consume fish?
More than once per week
Once per week
Less than once per week
Never
Don't know
How much wine do you consume per week? (1 glass = < 6 oz)
Less than 1 glass per day
1 - 2 glasses per day
More than 2 glasses per day
How much other alcohol do you consumer per week? (1 glass = < 1 oz for hard liqor or 8 oz for beer)
No alcohol other than wine or no alcohol at all
Less than 1 glass per day
1 - 2 glasses per day
More than 2 glasses per day
Have you ever been diagnosed with depression or another mood disorder?
Yes
No
Don't know
Do you live with other people in one household?
Yes
No
Don't know
Do you maintain regular (once a week or more) social contacts?
Yes
No
Don't know
Do you often feel isolated from other people or alone?
Yes
No
Don't know
Is air pollution a concern in your neighborhood? (E.g., due to proximity of a major highway)
Yes
No
Not sure
How many hours of sleep do you usually get?
< 5
5 - 6
6+ - 7
> 7
Do you usually wake up feeling rested?
Yes
No
Don't know
Do you suffer from any chronic illnesses or pain?
Back
Next
Section 5: Medication
Have you in the past taken estrogen? (E.g., as part of oral contraception or for the treatment of menopausal symptoms)
Yes
No
Don't know
Do you or have you in the past taken vitamin E?
Yes
No
Don't know
If yes, what did you take it for?
Submit
Should be Empty: