Name First Last PhoneEmail Which of the following best describes you?Please select from dropdown ⌄Enquiring on behalf of a friendEnquiring on behalf of a relativeEnquiring on behalf of a spouseEnquiring on behalf of selfThe age of the person you are inquiring for?Please select from dropdown ⌄Under 1818-2425-3435-4445-5455-6465 or AboveSelect the most relevant option for you or the one you are inquiring for:Please select from dropdown ⌄Subtle memory changesMild Cognitive ImpairmentDementiaAlzheimer’s diagnosisOther form of dementiaI have no memory concernsDo you or the person you are requiring for have any condition that would prohibit the ability to get a PET scan or MRI (pacemaker, retained metal, claustrophobia)?Please select from dropdown ⌄YesNoI’m not sureIn the past 5 years have you or the person you are inquiring for been diagnosed or treated for cancer?* Yes No In the past 2 years have you or the person you are inquiring for experienced a stroke or heart attack?* Yes No Do you or the person you are inquiring for have a history of diagnosed mental illness (bipolar, schizophrenia)?* Yes No Please tell us more about what interests you in memory studies?Where did you first hear about Re:Cognition Health?Please select from dropdown ⌄FacebookWebsiteCognicitiPrint AdvertisementOtherPhoneThis field is for validation purposes and should be left unchanged. Δ