Below is a short memory Evaluation which will assist Dr. Steinberg in assessing potential
indicators related to Alzheimer’s Disease. Thank you for your honesty.

Please respond to the questions in order. If you are unable to answer a question
within 10 seconds (unless typing itself is slowing you down), please proceed to
the next question. Do not leave any question blank and then return to it later.
Please do not refer back to any questions once you have moved to the next.

To Print this Test, select File->Print.

Name:  

E-mail:



Question 1
Are you
Married
Single
Widowed
Divorced

Facilitator:




Question 2
What is your date of birth?

Facilitator:

Question 2a
How old are you?

Facilitator:

Question 3
Do you have children? (multiple choice)
Yes, living away
Yes, living same residence
No

Facilitator:

Question 3a
If yes, what are their names?

Facilitator:

Questions 4
What is the highest grade of school, you completed?

Facilitator:

Question 4a
What type of work did you do most of your life?

Facilitator:

Question 5
Have you ever suffered from a significant stroke?
(such that there is extended impairment to your speech or motor skills)
Yes       No

If yes, what was the impact to your functioning,
e.g. unable to walk, unabale to use right or left side of body, speech impairment?

Facilitator:

Question 5a
Did you ever drink alcohol to excess?
Yes       No

If yes, are you still drinking or when did you stop?

Facilitator:

Question 5b
Did you ever have to see a psychiatrist for depression or "nerves"?
Yes       No

If yes, when and for what reason(s)?


If yes, were you ever hospitalized for depression or nerves?
Yes       No

Facilitator:

Question 5c
Are you presently being treated by a physician or therapist for depression or "nerves"?
Yes       No

Facilitator:

Question 5d
Please list any medications which you are currently prescribed:

Facilitator:

Question 5e
Please list any medical conditions for which you received medical treatment,
past and present, e.g. heart disease, blood pressure, Diabetes:

Facilitator:

Question 6
What year is it?

Question 7
What Month is it?

Facilitator:

Question 8
What is today’s date?

Facilitator:

Question 9
What day of the week is it?

Question 10
What is your complete home address, including zip code?

Facilitator:

Question 11
Who is the president of the United States?

Question 11a
Who was the President before Him?

Question 12
Please subtract 7 from 100, and continue to do so until time on the clock runs out
(20 seconds).
Fill out your answers in the boxes below, starting at the top.
(Use the "TAB" key on your keyboard to jump from box to box)
Please press the Start button below to begin the timer on the clock.

Question 13
Name the following objects by typing in the name of the object below each image.
- Spelling is not important.

Please repeat the names of these items out loud,
once or twice, as you will be asked to recall them
in a few minutes.

Question 14
With whom do you live?

Facilitator:

Question 14a
In what type of dwelling to you live, e.g. house, apartment, assisted living facility?

Facilitator:

Question 15
Who takes care of activities for daily living such as shopping, managing money,
cooking, and cleaning?

Facilitator:

Question 16
Do you drive?
Yes       No

Facilitator:

Question 16a
If so have you had any accidents in the past year?
Yes       No

Facilitator:

Question 16b
Do you find yourself getting lost driving even short distances?
Yes       No

Facilitator:

Question 17
How would you describe your mood in general?

Facilitator:

Question 18
Do you feel depressed or anxious?

Question 19
How is your appetite?

Facilitator:

Question 19a
If you have difficulty with your appetite, is this a recent change or long-standing?

Facilitator:

Question 20
How is your sleep, e.g. normal, difficulty falling asleep, waking up throughout the night?

Facilitator:

Question 20a
Is this sleep pattern new or long-standing?
New      Long-standing

Facilitator:

Question 21
Do you sometimes find yourself struggling to find the right words or phrases
in daily conversation?
Yes       No

Facilitator:

Question 22
A few moments ago you were asked to identify three items.
Please write down the names of those three items.
     

You have now completed the questionnaire. The person facilitating
the process should now go through the questions and, where requested,
1) indicate in the provided space if the individual was correct
or incorrect in his or her response, and 2) provide additional
information if the response was incomplete.

Once all the responses have been completed, please click the "Submit" button
below to submit payment for this assessment. This payment will be submitted
over our secure server.

Please allow up to 48 hours for Dr. Steinberg’s report.