Survey Form

First Name

Email

Country

Age

Sex

Education

Family history of early dementia¹ or genetic predisposition²

¹Before 65 years of age

²Positive for the ApoE4 gene or other dementia related genes

Weight[kg]

Height[cm]

Healthy Diet
How many portions per day of raw and/or cooked fruits/vegetables you eat?

Healthy Diet
How many portions per week of fish you eat?

Alcohol
How much alcohol do you regularly drink per week?

Smoking

Physical activity
Do you regularly engage in physical activity (i.e., recreational walking) and how often?

Physical Activity
Do you regularly engage in gym (fitness exercises), sport or intensive leisure activity and how often?

Cognitive activity
About how much time do you spend reading each day (newspapers, magazines or books), including online reading?

Cognitive activity
For the past year/month how often did you play "brain games"?¹

¹Like checkers or other board games, cards, puzzles, word games, mind teasers, or any other similar games (This includes online games)

Cognitive activity
For the past year/month how often did you write letters or emails?

Cognitive activity
For the past year/month how often did you use online social network activities like facebook/ twitter?

Sleep
Do you have problems initiating sleep, trouble maintaining sleep, or waking up early and not being able to go back to sleep?

Sleep
Do you have sleep-disordered breathing (snoring or sleep apnea)?

Sleep
Are you taking any sleeping pills regularly?

Have you ever been diagnosed with the following conditions or are you taking any related meds?

Diabetes
Diabetes (elevated blood sugar)

Elevated Cholesterol
Elevated Cholesterol (more than 200 mg/dl or taking cholesterol lowering drugs)

Hypertension
Hypertension (elevated blood pressure or taking blood pressure lowering drugs):

Depression
Depression or taking anti-depressant drugs

Heart disease
Coronary Heart disease

Cardiovascular
Cardiovascular disease or Stroke

Renal dysfunction
Renal dysfunction (chronic kidney disease):