The Alzheimer’s Solution Risk Assessment

Non-Modifiable Risks

1) What is your age?
2) Do any of your immediate family members (mother, father, sister, brother) have a history of Alzheimer’s or Dementia before the age of 65?
3) If you selected other, please select the number of other first-degree family members with history of Alzheimer’s or dementia before the age of 65?
4) Do any of your immediate family members (mother, father, sister, brother) have a history of Alzheimer’s or Dementia after the age of 65?
5) If you selected other, number of other first-degree family members with history of Alzheimer’s or dementia after the age of 65?
6) Do any of your immediate family members (mother, father, sister, brother) have a Vascular Disease (Stroke, Heart Disease, Peripheral Vascular Disease)?
7) If you selected other, number of other first-degree family members with vascular disease (Stroke, Heart Disease, Peripheral Vascular Disease)
8) Have you had genetic testing? If so, what were your results for APO?
9) What were your other genetic results?


Modifiable Risks

1) What foods and beverages have consumed daily (on the average) in the last two years? (Select all that apply.)
2) If you consume more than 5 tsp (25 grams) of sugar per day, select the number for each additional tsp beyond the 5 tsp (25 grams).
3) How much do you exercise?
4) How much time per day do you spend inactive?
5) How much stress do you deal with in your life?
6) Do you engage in meditation, mindfulness exercises or walking to mitigate stress?
7) What’s the quality of your sleep? (Select all that apply.)
8) How mentally challenged are you on a daily basis?
9) How socially engaged are you?
10) Do you suffer from any of the medical conditions below and do not receive treatment? (Select all that apply.)

Fill out the form below to get your final modifiable results.


Name
Email

Your Non-Modifiable Results will be emailed to you upon completion. If you’d also like to keep record of your Modifiable results, print this page.

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