Exit this survey MHNM1505- Patients NY / PA 1. Question Title 1. Please complete the contact information below. First and Last Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title 2. Please supply us with a secondary contact number. Murray Hill Center standard policy requires at least two contact numbers for each respondent. If the secondary number you give us is not your own number but a friend, family member or co-worker please indicate as such. Question Title 3. What is your gender? Male Female Question Title 4. What is your current age? Question Title 5. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title 6. What is your current work status? Full-Time Employed Part-Time Employed Homemaker Unemployed / Looking for work Retired Student Full-Time Question Title 7. What is your Occupation-Job Title, Company you work for, and Industry? (If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major) Occupation: Company: Industry: Question Title 8. 8. What is the highest level of education that you have completed? Some High School or less High School Graduate or GED Some College - No degree 2 yr College Degree / Associates 4 yr College Degree / Bachelors Post Graduate Work / Degree Question Title 9. 9. What is your current marital status? Single - Never Married Single - Divorced Single - Widowed Single - Separated Live with Partner / Co-Hab Married Question Title 10. Do you live........ c In your own home or apartment alone or with spouse/partner c With another relative (not your spouse/partner) c In an independent living/retirement community c In an assisted living facility c In a nursing home or rehabilitation facility c In another type of institution Question Title 11. Have you noticed that your memory is not what it used to be? Yes No Question Title 12. Do you find that changes in your memory interfere with your daily activities? Yes No Question Title 13. Over the last 6 months, has your memory c Stayed about the same or improved c Gotten worse Question Title 14. Did you mention your memory concerns to your physician? Yes No Question Title 15. When did you first discuss your memory concerns with your doctor? c In the past 1 year c 1-2 years ago c 3-4 years ago c More than 4 years ago Question Title 16. What did your doctor say you had? (Please mark all that apply. c Normal aging c Age-related memory loss c Dementia c Mild cognitive impairment c Pre-Alzheimer’s disease / Early Alzheimer’s c Alzheimer’s c None of these Question Title 17. Did the doctor offer a prescription medicine for your memory concerns? This could be a conversation that occurred even if you didn’t take the medication. Yes No Question Title 18. Do you currently take a prescription medicine for memory concerns? Yes No Question Title 19. What medicines do you currently take for your memory or thinking concerns? Please check all that apply c Aricept (donepezil) c Razadyne (galantamine) c Namenda (memantine) c Exelon (rivastigmine) c Namzaric (memantine and donepezil) c I don’t know the name Other (please specify) Question Title 20. Have you been diagnosed with any of the following? (Please mark all that apply.) c Brain trauma c Huntington’s disease c Parkinson’s disease c Schizophrenia c Stroke/TIA c Vascular dementia c Lewy body dementia c Picks dementia c Epilepsy c Frontal temporal dementia c None of the above Question Title 21. Which of the following do you need help with? (Please mark all that apply.) c Performing household tasks and errands c Managing day-to-day finances c Planning events and scheduling c Getting dressed c Bathing c Using the bathroom c None of these Question Title 22. Are you comfortable using a computer to type emails or look at websites for news or shopping? Yes No Next
