Assessment Job Submission

* Age

Height in

Enter your height, e.g. 5'5''

Race Select your race White Black/African American American Indian/Alaska Native Hispanic/Latinx Asian Middle Eastern Other

Do you have a first-degree relative (mother, father, sister, brother) living or deceased with a memory problem?
--Please choose an option-- YES NO

Has a doctor, nurse, or other healthcare professional ever told you that you have a memory or thinking problem or diagnosed you with a specific memory and thinking problem? --Please choose an option-- YES NO Unknown

Have you been diagnosed with any of the following medical condition(s): cirrhosis of the liver, cancer, heart disease, COPD, kidney disease requiring dialysis, or diabetes? --Please choose an option-- YES NO

How often do you exercise or walk for more than 10 minutes (without stopping)? --Please choose an option-- Rarely/Never 1 time each week 2-3 times each week 4 or more times each week

How often do you drink alcoholic beverages? --Please choose an option-- Rarely/Never Occasionally Weekly Daily

How long have you been smoking cigarette or pipes during your entire life? --Please choose an option-- Rarely/Never Less than 5 years 5-9 years 10-20 years More than 20 years

Do you have trouble recalling things more than you did in the past 5 years? --Please choose an option-- YES NO

Do you have trouble using household appliances? --Please choose an option-- YES NO

* Step 1: Take Clock Drawing Test

Please click on the Start Taking Clock Drawing Test button to get the instructions and complete the test independently.

Then submit a picture of your drawing here (Accepted file formats are PNG and JPEG.):

* Step 2: Take Trail A Test

Please click on the Start Taking Trail Test button, print out the instructions and follow them to complete the test.

How long did it take you to complete the test? minutes seconds

Please submit a picture of your test result here (Accepted file formats are PNG and JPEG.):