Baseline Cognitive Assessment Form
Please complete this form to help us evaluate your current cognitive abilities. Your responses will remain confidential and are used for assessment purposes only.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Highest Level of Education Completed
*
Please Select
No formal education
Primary school
High school
Associate degree
Bachelor’s degree
Master’s degree
Doctorate or higher
Other
How would you rate your current memory?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Please indicate how often you experience the following difficulties:
*
Rows
Never
Rarely
Sometimes
Often
Always
Forgetting recent events
1
2
3
4
5
Difficulty concentrating
6
7
8
9
10
Trouble finding words
11
12
13
14
15
Losing track of time or place
16
17
18
19
20
Difficulty following instructions
21
22
23
24
25
Orientation: What is today’s date?
*
Attention: Please repeat the following sequence backwards: 3, 8, 1, 4, 7
*
Language: Name as many animals as you can in 60 seconds (list them below)
Reasoning: If you found a stamped, addressed envelope on the street, what would you do?
Submit Assessment
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