Research Phone: (518) 426-0575 • Clinic Phone: (518) 449-2662 info@naaresearch.com

Pre-Screening Memory Questionnaire

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Last
What is the best time to contact you
What is the best way to contact you
I am interested in information for:
Have you noticed a decline in memory function
Have you talked to a doctor about memory problems
If you answered "yes" please check all exams completed:
Have you been diagnosed with a memory disorder
Are you taking any memory related medications?
In addition to a study participant, our studies involve having a caregiver, friend or family member attend study visits with the participant for the duration of a study. Is there someone you think could attend visits with the participant?