Cognition Assessment

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

5

What country are we in?* This field is required.

Canada

England

United States

Mexico

6

Repeat these three words.

"Apple Pen Table"

7

What were the three words?* This field is required.

Apple, Orange, Table

School, Pen, Paper

School, Pen, Table

Apple, Pen, Table

8

What is 7 minus 2?* This field is required.

3

5

1

4

9

Starting from 100, subtract 7 repeatedly five times. What is the final number?* This field is required.

75

65

85

78

10

What is the name of this object?

11

What is the name of the object?* This field is required.

Pencil

Paper

Pen

Eraser

12

Repeat the following phrase: "No ifs, ands, or buts." Were you able to repeat the following phrase?* This field is required.

YESNO

13

If someone asks you to close the door, what should you do?* This field is required.

Open the door

Ignore the request

Sit down

Close the door

14

Which shape is a circle?* This field is required.

15

Which one does not belong in the group: Apple, Banana, Carrot, Orange?* This field is required.

Apple

Banana

Carrot

Orange

16

What were the three words from question #3?* This field is required.

Apple, Orange, Table

School, Pen, Paper

School, Pen, Table

Apple, Pen, Table

17

Cognitive ScoreClick next to see what it means

18

You have no cognitive impairment! If you are still concerned or are concerned about your loved one or someone close to you suffering from dementia or cognitive impairment, click next.

19

You have mild cognitive impairment. If you are concerned about your results and would like to learn about possible treatment options or a professional diagnosis, please click next.

20

You have severe cognitive impairment. If you are concerned about your results and would like to learn about possible treatment options or a professional diagnosis, please click next.

21

Would you be interested to speak to our patient coordinator?* This field is required.

YESNO

22

Preferred Contact Method* This field is required.

Call

Text

Email

23

When is the best time to reach you?* This field is required.

Morning

Afternoon

Evening