Cognitive Testing

Name

First

Last

Email

Date of Birth

Insurance Insurance

Phone

Store

Scheduling by store is only offered up to two weeks in advance as we match the testing device to the pharmacist schedule. Please check back regularly for more appointment openings as they become available.

Appointment Oak Harbor

Appointment Clinton

Appointment La Conner

Visuospatial: Do you...

Feel or have you been told you are clumsy moving around?

Often stumble with things that are near you?

Have difficulty reading and/or getting dressed?

Have difficulty driving and/or parking your car?

Have had any car accidents in the past year?

Executive Function: Do you...

Have difficulty concentrating on tasks? (such as following recipes, creating lists, and work related projects)

Feel it takes longer to plan and complete tasks than you’d like?

Have difficulty keeping track of your monthly bills and/or balancing your checkbook?

Feel short-tempered and/or fighting with anyone recently?

Feel or have you been told that you’re making poor decisions lately?

Feel you are paying less attention to your hobbies and/or social events you usually enjoy?

Naming/Language: Do you...

Have difficulty following a conversation?

Sometimes have difficulty finding words to describe things?

Find it difficult to text, email or write notes/letters to people?

Memory and Delayed Recall: Do you...

Have difficulty remembering things?

Misplace things often and have a difficult time finding them?

Have difficulty remembering important birthdays and/or anniversaries?

Have missed a routine appointment lately (such as doctor, dentist, etc)?

Have gotten lost recently?

Lifestyle: Do you...

Make an effort to eat a balanced diet on a regular basis?

Exercise regularly and/or take long walks?

Like to go out with friends/family and do you continue share common interests with them? q Feel stressed, overworked and/or overwhelmed with your life?

How often do you drink alcohol during the week? __________ (answer in other box)

How many medications do you take per day? __________(answer in other box)

OtherOther

Sleep Disorders: Do you...

Feel fatigued during the day?

Wake up several times during the night?

On average, how many hours do you sleep per night? __________ (answer in other box)

OtherOther

Cardiovascular: Do you...

Have high blood pressure? If so, how well controlled is it? _____(answer in other box below)

Have a history of heart problems?

Have trouble breathing or exercising?