Let's Solve Alzheimer's/Dementia Together
What age did you first notice "symptoms"
20-30
30-40
40-50
50-60
60-70
70-80
80+
What medications were taken "long-term" (more than 6 months) - chose any/all that fit
Antidepressants
Statins - for high cholesterol
Diuretics - for high blood pressure
Other high blood pressure medicines
Antacids for heart burn
Multivitamins
Antipsychotics or other mood altering medicines
Allergy medicines
Corticosteroids - inhaled, creams or pill form
Birth control
Antivirals
Antibiotics
None
How much sleep per night?
Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours
Sleep quality - chose any/all that fit
Light sleeper
Out cold for the night
Woke up rested
Woke up unrested
Screen use in the evening - chose any/all that fit
Watched a lot of evening tv
Used phones/tablets/computers routinely before bed
Little to no phone/tv/electronic use before bed
Fell asleep to the tv regularly
Slept with a nightlight
Slept in complete darkness
Major illness - chose any/all that fit
Never had any major illnesses/injuries
Broke bones
Head trauma
Major infections - repeatedly and/or requiring hospitalization
Herpes
Syphilis
Other STDs
Chicken pox
Malnutrition/starvation/eating disorder
Mental illness - any
Parkinsons
Used iodized salt
Yes
No
Overweight in childhood
Yes
No
Overweight in adulthood for more than 3 years
Yes
No
Wore sunglasses outside regularly
Yes
No
Had metal fillings in teeth
Yes
No
Exposed to nail polish remover, pipe glues, lead paint, leaded gasoline, or other solvents more than "normal"
Yes
No
Was your mother stressed while pregnant with you
Yes
No
Don't know
Were you extremely stressed, experienced major traumas, unable to cope with life
Yes
No
Any relatives have alzheimer's or dementia - chose any/all that fit
No
Yes - sibling
Yes - parent
Yes - aunt/uncle
Diet
Vegan
Vegetarian
Pescatarian
Carnivore
Omnivore
Fast food consumption
Almost never
Once a month
Once a week
2-3 times per week
Daily
Did you regularly drink diet soda (more than once a week)
Yes
No
Activity levels
Couch potato
Moderately active
Daily exercise
Marathon runner, extreme sports, extremely active
Any history of diabetes or pre-diabetes
No
Diabetic
Pre-diabetic
Any history of suicide attempts
No
One time
Multiple attempts
Emotional Management
Yell/scream when angry
Stuffed your feelings
Food history - chose any/all that fit
Most meals cooked "from scratch" with whole food ingredients
Many treats - cakes, cookies, candies
Mostly ate in restaurants
Most meals came from boxes, cans, freezer
Any thyroid issues
Yes, hyperthyroid
Yes, hypothyroid
No
Unknown
Marriage history
Married
Divorced
Never married
Social connections
1-2 close friends
Mostly alone
3-5 close friends
5+ close friends
Poverty
Lived in poverty during childhood
Never lived in poverty
Lived in poverty during adulthood
Career
Had a career I loved
Had a career I hated
Bounced from job to job
Egg consumption
Ate eggs regularly (2+ times per week)
Hated eggs and avoided them
Ocean Seafood
Never ate it
Ate seafood sometimes
Ate seafood at least once a week
Pregnancy
Never pregnant - female
Never pregnant - male
1 pregnancy
2 pregnanies
3 pregnancies
4 or more pregnancies
Gender
Male
Female
Wore corrective lenses - glasses, contacts, lasik surgery
Yes
No
Did you have High Blood pressure
No
Yes and it was treated with medication
Yes and it was untreated most of the time
Did you ever suffer a stroke, mini stroke, or temporary neurological paralysis (bells palsy etc)
Yes
No
Did you have migraine headaches
Yes, infrequently
Yes, every week
Yes, every day
No
Did you regularly suffer from stomach issues - chose any/all that fit
No
Yes, regular painful gas
Yes, regular indigestion
Yes, regular heartburn
Yes, regular diarrhea
Yes, regular stomach pain
Yes, regularly bloated
Which was your "treat/snack" of choice - Choose one or more if applicable
Potato chips
Chocolate
Bagels, breads
Hard or chewy Candy
Gum
Tortilla chips
Baked goods - brownies, muffins, cakes, cookies, donuts
Granola bars
Popcorn
Fruit
Drinks - soda, fruit juice, energy drinks
Smoker
Yes
No
Drinking Water
Well
City water
Did you like vegetables
No
No, but I ate them everyday anyway
Yes, ate them at least once a day
Yes, ate them with most meals
Insect exposure
Regularly bit by mosquitoes each summer
Hardly ever or never had a tick or mosquito bite
Exposed to bed bugs
Exposed to chiggers
Regularly bit by ticks each summer
Regularly bit by deer flies and horse flies
Did your job involve physical labor
Yes
No
Outdoor exposure
Stayed indoors if I could
Many outdoor hobbies
Worked outdoors
Went outside - for a walk, to garden, to talk with neighbors at least once a day
Did you notice an "Unwashable" body odor when symptoms first began?
Yes
No
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