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Participation in the Alzheimer's Foundation of America (AFA) National Memory Screening Day survey is voluntary. We do not ask for your name or other personal information, but we do put in a code for your site and your participation order. The information you provide will assist AFA in its memory screening initiative. Please complete this survey by indicating your answers by clicking the relevant boxes. When you have completed the survey please inform your screener to complete and submit the form. Thank you for your assistance.
Please start by entering your individual ID code: Site ID Code: Participant ID Code:
1. Are you male or female? Male Female
2. What is your age? Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 and over
3. What is your primary race? White Black or African American American Indian or Native American Native Hawaiian or other Pacific Islander North Asian (for example, Chinese, Japanese) Middle Eastern / South Asian Other I prefer not to answer
4. Are you of Hispanic ethnic background? Yes No
5. What is the highest level of education you have completed? (Check only one) Grade school High school Some undergraduate courses Undergraduate degree Graduate degree Unknown/other
6. When was the last time you saw a primary healthcare provider? (For example, doctor, nurse practitioner) Within the past six months Between six months to one year ago Between one to two years ago Longer than two years ago
7. Have you participated in the Medicare Annual Wellness Visit? Yes No
7a. If “Yes,” did you receive a cognitive assessment/ memory screening at that time? - - Yes - - No
8. Have you received any of the following screenings at a primary care provider’s office? (Check all that apply) Blood pressure screening Cancer screening Cholesterol screening Depression screening Diabetes screening Glaucoma screening Memory screening Other (specify): I have never received a screening of any kind at a primary care provider’s office
9. Why did you come in today for a screening on National Memory Screening Day? (Check all that apply) I have relatives with Alzheimer’s disease I have noticed that I am more forgetful these days I have gotten lost when I was outside my house My family or friends have encouraged me to get screened My employer suggested that I have my memory checked I want to see how I will do and obtain a score for future comparison I feel this is important to do regularly I have received a diagnosis of mild cognitive impairment (MCI) I have received a diagnosis of Alzheimer’s disease Other (specify):
10. If today’s screening test results suggest a need for further evaluation, which type of healthcare provider will you follow up with first? (Check only one) Primary care physician Neurologist Nurse practitioner Mental health professional (for example, psychiatrist, psychologist, counselor) Other health specialist (specify):
11. Has your primary healthcare provider ever given you a memory screening? Yes No 11a. If you checked “Yes” in Q.11, when did you have the memory screening? Within the past year Longer than one year ago
12. Has your primary healthcare provider (for example, doctor, nurse practitioner) ever provided information on ways to protect your memory / help reduce risk factors for Alzheimer’s disease? Yes No
13. Are you doing any of the following to help protect your memory? (Check all that apply) Mental stimulation (For example, doing puzzles, playing board games, doing brain exercises, etc.) Managing stress Eating a healthy diet Limiting alcohol consumption Taking nutritional supplements Socializing more Controlling other health risk factors, such as depression and high blood pressure Physical exercise. (if you select this option, please answer questions 13a and 13b, below) Other (specify):
13a. If you checked “Physical exercise” in Q.13, how many times per week do you exercise? 1-2 3 or more
13b. If you checked “Physical exercise” in Q.13, what type(s) of exercise do you do? *Check all that apply) Walking Running (indoors or outdoors) Cycling Swimming Weights Other (specify):
14. In the last year, have any of the following incidents happened to you when you were driving? (Check all that apply) Difficulty staying in your lane Drivers honking at you Being lost in familiar areas A speeding ticket Pulled over by police Motor vehicle accident resulting in a fender-bender Motor vehicle accident resulting in an injury Motor vehicle accident resulting in a death Other (specify): I have not driven in the past year (do not check if you have checked any of the above)
15. Have you experienced memory lapses that have caused you to be concerned about your memory? Yes (continue to Question 16) No (go directly to Question 18)
17. Have you shared your memory concerns with a healthcare professional in the past (other than on National Memory Screening Day)? - - (Answer for Yes or No below) Yes. Why? (Check all that apply): I have relatives with Alzheimer’s disease I have noticed that I am more forgetful these days I have gotten lost when I was outside my house My family or friends have encouraged me to get screened My employer suggested that I have my memory checked My primary healthcare provider asked me about my memory I was aware that my healthcare professional could provide me with a memory screening I was aware that detection of cognitive impairment is part of the Medicare Annual Wellness Visit I previously got screened on National Memory Screening Day and wanted to follow up Other (specify): No. Why not? (Check all that apply): I did not think my memory issues were severe enough I thought Alzheimer’s disease is a normal part of aging I did not know if my healthcare professional could provide me with a memory screening I thought I was too young to have Alzheimer’s disease or a related dementia My healthcare provider never asked me about my memory I was concerned about being labeled with this disease I did not want to think about it I believed that since there is no cure for Alzheimer’s disease, there was no point My family discouraged me from raising the issue I did not have health insurance I did not know that detection of cognitive impairment is part of the Medicare Annual Wellness Visit Other (specify):
18. Did you get a memory screening on National Memory Screening Day in any of these years? (Check all that apply) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
19. In what type of setting(s) would you feel comfortable receiving a memory screening? (Check all that apply) Doctor’s office Senior center Clinic Hospital Alzheimer’s organization Library Social service agency House of worship Pharmacy or drug store Assisted living facility Supermarket/ convenience store Other (specify):
20. Do you have any additional comments or suggestions?
------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------- Thank you so much for completing this voluntary survey. Please tell your screener that you are finished with this survey. ------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------
FOR OFFICIAL USE ONLY — TO BE COMPLETED BY SCREENER 1. In what type of setting is this screening being held? Doctor’s office Alzheimer’s-specific organization Social service agency Senior center Clinic Hospital Pharmacy or drug store Assisted living facility Supermarket/convenience store Library House of worship Other (specify):
2. Please list the 5-digit zip code where the screening site is located:
3. Which screening instrument was used for this participant, and what was their score? BAS: Score GPCOG: Score / 9 Mini-Cog: Score / 5 MIS: Score / 8 Kokmen: Score / 38 MMSE: Score / 30 MoCA: Score / 30 Other (specify and note score and range):
4. Did you encourage the participant to follow up with his/her physician or other healthcare professional? Yes No
5. Additional comments (optional):
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