Dementia Risk Assessment

Name*

First NameLast Name

Email*

example@example.com

How many family members do you have with Alzheimer's disease or any other form of dementia?

1 family membermore than 1 family memberno family history

Answer YES, if they apply to you, and NO if they do not apply to you.

	Yes	No
A single head injury with loss of consciousness OR several head injuries without loss of consciousness
Alcohol or drug dependence in past or present
(FEMALE) Major depression or ADD/ADHD diagnosed by a physician in past or present {answer NO if you are MALE, or if you are female and have not received these diagnoses}
(MALE) Major depression or ADD/ADHD diagnosed by a physician in past or present {answer NO if you are FEMALE, or if you are male and have not received these diagnoses}
Being overweight
History of a stroke
Heart attack or heart disease
Prehypertension or hypertension
Prediabetes or diabetes
Cancer chemotherapy
Seizures in past or present
Parkinson's disease
Sleep apnea
Less than a high school education
Limited exercise, less than two times per week
Jobs that do not require new learning
Periodontal disease
Presence of inflammation in the body, such as: high ESR (erythrocyte sedimentation rate), high homocysteine, high c-reactive protein, autoimmune disorders
Smoking cigarettes for 10 years or longer
Low estrogen in females OR low testosterone in males or females
Within the age range 65-74
Within the age range 75-84
Age 85 or older
Do you consume MORE grain products, meats, eggs, nuts and dairy THAN fruits and vegetables?

Peak Brain Health – Memory Care & Dementia Services – supports you and your loved ones to live well

Contact us to find out more about: memory care, caregiving resources, respite/companion services, dementia support and consult services, creative approaches to dementia, brain health and wellness programs/services we have to support you.

Dementia is not a normal part of ageing, and can occur in younger people. However, the risk increases as you age, especially after 65.

Some dementia risk factors are modifiable. We can help.

Contact:Peak Brain Health

SCHEDULE AN APPOINTMENT: PEAK BRAIN HEALTH

If you are concerned about yourself or a loved one, we offer supports for “Living Well with Dementia”.