How Well Are You Thinking? - Elder Guru

self administered gerocognitive examination - sage Form 1 How well Are You Thinking? Please complete this form in ink without the assistance of Date of Birth _____/_____/_____How far did you get in school? _____ I am a Man_____ Woman_____I am Asian_____ Black_____ Hispanic_____ White_____ Other_____Have you had any problems with memory or thinking ? Yes_____ Only Occasionally_____ No_____Have you had any blood relatives that have had problems with memory or thinking ? Yes_____ No_____Do you have balance problems? Yes_____ No_____If yes, do you know the cause? Yes (specify reason)_____ No_____Have you ever had a major stroke? Yes_____ No_____ A minor or mini-stroke? Yes_____ No_____Do you currently feel sad or depressed?

Self Administered Gerocognitive Examination - SAGE Form 1 How Well Are You Thinking? Please complete this form in ink without the assistance of others.

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