Dementia Prognostic Tool - Knowledge Translation

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As a first step in improving your brain health, please answer the following questions so we can better understand your health.

1. What is your age?
          *
2. What is your sex?
          Male   Female *
3. What is your height in inches?
          *
4. What is your weight in pounds?
          *   BMI
5. Have you had a brain injury in which you were confused for more than a week?

Yes No *

6. Have you had two or more concussions?
Yes No *

7. Have you been diagnosed with post-traumatic stress disorder?
Yes No *

7a . Has your PTSD been successfully managed?
Yes No *

8. Have you been diagnosed with hearing loss?
Yes No *

8a. Do you regularly use a hearing aid?
Yes No *

9. Have you been diagnosed with hypertension (high blood pressure)?
Yes No *

9a. Do you regularly take medication to control your hypertension?
Yes No *

10. Have you been diagnosed with Diabetes type II?
Yes No *

10a. Does your doctor say that your diabetes is well-managed?
Yes No *

11. Have you been diagnosed with Depression?
Yes No *

11a. Has your depression been successfully treated?
Yes No *

12. Do you currently smoke cigarettes?
Yes No *

12a. If no but you smoked in the past, have you quit for the last 4 or more years?
Yes No NA *

13. Have you ever been diagnosed with alcohol use disorder?
Yes No *

13a. If yes, do you abstain from drinking alcohol?
Yes No *

13a. In a typical week, do you have more than 14 alcoholic drinks?
Yes No *

14. Do you walk or exercise for at least 30 minutes, 5 or more days a week?
Yes No *
15. Have you been diagnosed with a sleep disorder?
Yes No *

15a. On a typical night do you get 6 or more hours of sleep?
Yes No *

15a. Has your sleep disorder been successfully managed?
Yes No *

16. Have you had a blood test to see if you may be at increased risk for dementia?
Yes No *
All fields required*

Age is outside of range of 18-99

Please complete the required field(s).

Please complete age, sex, weight, and height fields

Height is outside of range of 36-120 inches

Weight is outside of range of 50-500 pounds

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