Step 1 of 21 - Demographics

4%
This field is hidden when viewing the form
I agree to the terms and conditions(Required)
What is your gender?(Required)
Please enter a number greater than or equal to 0.
Do you speak any other languages?(Required)

Please indicate how much you agree or disagree with the following statements:

There is nothing anyone can do to reduce their risk of dementia.(Required)
I am able to make differences that will change the risk of developing dementia(Required)
Changing my lifestyle and health habits can help me reduce my chance of developing dementia(Required)

Has your doctor told you that you have any of the following medical conditions?

A heart or blood vessel condition*
Chronic kidney disease
Diabetes
High blood pressure
High cholesterol
None of these

*including heart attack, angina (chest pain), heart failure, stroke or TIA’s (transient ischemic attack)

Do you have trouble with your hearing?(Required)
Do you smoke?(Required)
Your Body Mass Index (BMI) is 0
Do you regularly get at least 2.5 hours moderate exercise a week? This is approximately 30 mins a day.(Required)

How many units of alcohol do you drink in an average week? (one unit = half a pint of beer or a single measure of spirits or a small glass of wine)

Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
0 = Total units of alcohol in a typical week
The Mediterranean diet includes foods like fish, vegetables, legumes, olive oil, pasta and occasionally a glass of red wine. Does this sound similar to the way you eat?(Required)
How has your mood been in the past four weeks?(Required)
Do you generally engage in mentally stimulating activities, like learning new things, making music, or practicing hobbies?(Required)
Do you generally consider yourself as someone who is socially engaged, such as being involved in social activities?(Required)
How good would you rate the quality of your sleep on average?
This field is hidden when viewing the form
This field is hidden when viewing the form

Click here to reset the survey.