Medical Questionnaire – Cognitive Health Last Name(Required)First Name(Required)Date of birth(Required) DD dash MM dash YYYY To better characterize the etiology of your cognitive decline, check off all the items you find in your home (or in your caregiver with cognitive decline)Specific symptoms I’ve had a head injury in the past. I have a history of Alzheimer’s disease in my family. I had a long, slow and gradual cognitive decline. I had rapid cognitive decline in terms of days or hours. It is mainly the memory that is affected. I have visual hallucinations (often detailed). I have tremors. I have rigidity in my limbs. I have trouble sleeping (restlessness at night) I’ve noticed a recent change in vocabulary. I have disinhibition (I’m not embarrassed to do things that used to bother me or aren’t socially accepted). I’ve had a voracious appetite lately. I’ve noticed a lack of social etiquette recently. I (or someone close to me has) noticed an impairment of my judgment and/or reasoning. I had behavioural problems. I have an unstable gait. I have urinary incontinence. Subtype 1 I am a ApoE4 carrier (one or two copies). My cognitive decline started with memory loss. We saw a reduction in the size of my hippocampus during an MRI or brain scan. I regularly consume lectins (grains, legumes, etc.) I have insulin resistance or metabolic syndrome already diagnosed. I have a history of acute or chronic infections (bacterial, fungal, or viral). I’ve already been diagnosed with leaky gut. I have or have had poor gum health or repeated root canals. I am known for herpes problems (lip or genital). Subtype 1.5 I have diabetes or prediabetes. I have high blood sugar. I have known insulin resistance or metabolic syndrome. Subtype 2 I have a problematic history hormonally as a woman. I have a problematic history at the hormonal level as a man. I have confirmed hypothyroidism. I have suspected or confirmed nutritional deficiencies. I’ve already been told that I have brain atrophy. I’ve been told before that my homocysteine is high or that my methylation genes are problematic. Subtype 3 I have dental amalgam. I have already been diagnosed with Lyme disease. I’ve been in contact with mold before. I’ve been having trouble concentrating lately. I search or lose my words easily. I have or have had depressive episodes. I’ve already been diagnosed with zinc deficiency. Subtype 4 I’ve had a stroke or TIA (transient stroke/cerebral ischemia) before. I have cardiovascular problems (heart attack, angina, arterial blockage in my legs, etc.) I have a history of cardiovascular disease in my family. Have I had a rapid cognitive decline (in terms of days or even hours)? I smoke or have ever smoked cigarette. I’m overweight. I have high blood pressure. Subtype 5 I’ve had concussions in the past. CAPTCHA
