MindMate Research - Memory loss

You can always press Enter⏎ to continue

Now create your own JotForm - It's free!Create your own JotForm

Create your own JotForm

JotForm

JotForm mascot Podo

Question Label

1 of 16See AllGo Back

MindMate Research

Find out if you are eligible to participate in a research study. The test will take between 5-10 minutes to complete.

Language

English (US)

1
Are you completing this survey for yourself or a loved-one?
For myself
For my spouse
For my partner
For my sibling
For a friend
Press
Enter
2
Have you – or a loved one (if filling this out for them) – had memory loss that has become gradually worse over time?
YESNO
Press
Enter
3
Do you see a primary care physician for your memory problems?
YESNO
Press
Enter
4
Are you diagnoses by a doctor with one of the following conditions?* This field is required
Alzheimer's disease
Dementia
MCI (Mild Cognitive Impairment)
Memory loss (diagnosed by doctor)
Memory loss (undiagnosed)
Diabetes
Multiple Sclerosis (MS)
Healthy Volunteer
Schizophrenia
Psoriasis
Press
Enter
5
Do you - or your loved one (if filling this out for them) - have symptoms of agitation?
YESNO
Press
Enter
6
Have you – or a loved one (if filling this out for them) – experienced any of the following behaviors?Select all that apply
See things that other people nearby do not see
Hear things that other people nearby do not hear
Believe that something is true even when there is evidence that it is not true
Agitation (feeling restless or upset)
Aggression (feeling angry)
None of the above
Press
Enter
7
Do you – or a loved one (if filling this out for them) – have a family history of Alzheimer’s disease?
YESNO
Press
Enter
8
Are you – or a loved one (if filling this out for them) – able to undergo an MRI scan? MRI is Magnetic Resonance Imaging. It is a painless procedure that takes pictures/images of the brain.
YESNO
Press
Enter
9
Do you have a family member or friend who could accompany you during study visits?* This field is required
Yes
No
I'm not sure
Press
Enter
10
Name* This field is required
First Name
Last Name
Press
Enter
11
What is your Date of Birth?* This field is requiredPlease use the following format: MM/DD/YYYY
Press
Enter
12
Email* This field is required
example@example.com
Press
Enter
13
Phone Number* This field is required
Area Code
Phone Number
Press
Enter
14
Zipcode/Postcode* This field is required
Press
Enter
15
When would be a good time for a researcher to contact you (we try our best to call, text or email you at your preferred date and time)?
Press
Enter
16
Anything else you would like to tell us?
Press
Enter
Should be Empty:

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Sign up to save your submission

OR

Already have an account? LOGIN

Continue without sign up

Sign up with Email

UsernameEmail AddressPasswordConfirm Password

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Login to save your submission

OR

Username or emailPassword

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.