Memory Screening Appointment Request | Alzheimer's Foundation of America

Please choose how you would like to take your memory test, and an AFA representative will call you to schedule a time that works for you:*

BY APPOINTMENT ONLY

Name*

First Last

Address*

City State ZIP Code

Phone*

Email address*

As part of registration, you will be asked to answer several questions that will take just a few minutes. Your responses are completely confidential and help us better understand your brain health while ensuring we continue providing accessible, responsive, and person-centered supports nationwide. Your brain health matters. Early awareness supports informed decision-making.

Is this your first memory test?*

Yes
No

What is your age range?*

What is the highest level of education you have completed?*

Less than high school
High school diploma or GED
Some college (no degree)
Associate degree
Bachelor’s degree
Graduate or professional degree
Other
Prefer not to answer

This field is hidden when viewing the form

What is your gender?*

Woman
Man
Transgender
Non-Binary
Another identity
Prefer not to answer

Are you of Hispanic, Latino/a/x, or Spanish origin?*

Yes
No
Prefer not to answer

This field is hidden when viewing the form

What is your race? (Select all that apply)*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Another race
Prefer not to answer

What is your race? (Select all that apply)*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Another race
Prefer not to answer

What language would you prefer for the Memory Test to be administered in?*

English
Spanish

Have you noticed changes in your memory over the past year?*

Yes
No

Have your family members and/or friends expressed concerns about your memory over the past year?*

Yes
No

How often do you socialize with family members and/or friends each week on average?*

Every day
4-6 days per week
2-3 days per week
1 day per week
0 days per week

Do you have a family history of dementia?*

Yes
No

How often do you exercise on average per week?*

Every day
4-6 days per week
2-3 days per week
1 day per week
0 days per week

Do you enjoy mentally stimulating activities like crossword puzzles, riddles, reading books?*

Yes
No

How many hours do you sleep on average each night?*

8 hours or more
6 or 7 hours
Less than 6 hours

Do you smoke daily?*

Yes
No

How many drinks containing alcohol do you consume on average per week?*

7 or more per week
3 to 6 per week
1 or 2 per week
Less than 1 per week
0 per week

Are you a veteran or an immediate family member of a veteran?*

Yes, I am a veteran
Yes, I am an immediate family member of a veteran
No, I am not

How did you hear about this service?*

AFA website/email/social media
From Alzheimer's TODAY magazine
From a news story (newspaper, TV, radio)
From someone I know
From another organization

Consent for Memory Screening*

I have read and agree to the Terms of Service Agreement listed below

I understand that the results of all screening tests and information from the assessment administered as part of the National Memory Screening Program are preliminary and educational in nature, are for informational purposes, and are intended to provide me with information to facilitate a meaningful discussion with my physician or another qualified healthcare professional. The results and information are not intended to provide a diagnosis or recommendation for treatment/rehabilitation of any disease or health condition. The results of all tests and information from this program do not and should not take the place of talking with a physician or specialist. Only a physician or specialist can diagnose or recommend a treatment/rehabilitation program for any disease or health condition.
I hereby authorize a memory screening trained AFA staff person to administer a memory test to me as part of the National Memory Screening Program.

THIS INFORMATION WILL BE KEPT CONFIDENTIAL.

Thanks so much for your participation!!
An AFA representative will reach out to schedule your memory test within 2 business days.