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AFCA GENETIC SCREENING
P.A.D. (Parkinson's, Alzheimer's, & Dementia) Medical Qualifying Questionnaire
First Name
*
Last Name
*
Address
*
Address
Street Address Line 2
City/State/Zip
State / Province
Postal / Zip Code
Home Phone
Phone number
Cell Phone
*
Phone number
Email
*
example@example.com
Have you or your family had any of the following (Check all that apply):
Select all options that apply
*
Personal history of Parkinsons Disease, Alzheimers Disease or Dementia
Family history of Parkinsons Disease, Alzheimers Disease or Dementia
Abnormal imaging of the brain
Difficulty moving or controlling one's movement
Memory loss that interferes with daily life
Changes in mood or poersonality
Difficulty having a conversation
Difficulty completing familiar tasks or confusion with time or place
Please attach copies of the front and back of your ID and Insurance card below:
Front of ID
*
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Back of ID
*
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Front of Insurance Card
*
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Back of Insurance Card
*
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Who referred you to us?
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