Q1. How often have you noticed changes in your memory over the past 3 years? *

No noticeable change

Mild occasional forgetfulness

Sometimes forget important details

Frequently forget conversations or events

Significant worsening of memory

Q2. How often does memory difficulty affect your daily activities? *

Never

Rarely

Sometimes

Frequently

Almost always

Q3. How often do you experience brain fog or difficulty concentrating? *

Never

Rarely

Sometimes

Frequently

Almost daily

Q4. How often do you experience mental fatigue or lack of focus? *

Never

Rarely

Sometimes

Frequently

Daily

Q5. How often do you feel a lack of motivation, enthusiasm, interest, or drive? *

Never

Rarely

Sometimes

Frequently

Nearly every day

Q6. How often do you become confused about dates, the passage of time, or your surroundings? *

Never

Rarely

Sometimes

Frequently

Almost always

Q7. How often do you misplace important items such as your keys, wallet, phone, or glasses? *

Never

Rarely

Sometimes

Frequently

Daily

Q8. How often do you have difficulty with numbers, calculations, managing finances, or balancing a checkbook? *

Never

Rarely

Sometimes

Frequently

Severe difficulty

Q9. How would you rate your sleep quality? *

Excellent — I sleep well every night and wake up rested

Good — I sleep well and wake up rested most nights

Fair — I usually sleep well, but don't always wake up rested

Poor — I often have trouble falling or staying asleep

Very poor — I have trouble sleeping most nights and wake up tired

Q10. How many of the following metabolic risk factors do you have? *

None

One risk factor

Two risk factors

Three risk factors

Four or more risk factors

(Prediabetes/diabetes · high blood pressure · high cholesterol · excess abdominal weight · insulin resistance)

Has anyone in your family been diagnosed with Alzheimer's disease or dementia? *

Grandparent

Aunt/Uncle

Parent

Multiple First-Degree Relatives

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