Master of Memory (Pre-Series Evaluation)
Please take 5 minutes to complete this survey. There is no right or wrong answer for the pre series evaluation. This just helps us understand how our programs are doing and if we need to change it in any way to make it easier for the participants. Your participation is appreciated, thank you very much.
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First and Last Name *
Birthday (Month/Day/Year) *
Last four digits of your phone number *
Zip Code: *
County: *
Please answer YES or NO for each of the following statements based on if YOU believe the statement is true or false.
Statement *
YES
NO
Memory loss may be a normal part of growing older.
There may be things I can do to slow/stop my memory loss.
My memory is getting worse as I grow older.
High blood pressure may negatively affect my memory.
Physical activity, like walking, may positively affect my memory.
Depression may negatively affect my memory.
Certain health conditions may negatively affect my memory.
Hearing loss may negatively affect my memory.
I worry a lot about what I forget.
My memory is as good as it always was.
Loss of a spouse may negatively affect my memory.
Doing puzzles and playing games may positively affect my memory.
Taking certain types of medication may negatively affect my memory.
I need to talk to my health provider about my herbal supplements I take.
Some forms of memory loss may be treatable or reversible.
I can name at least two strategies to help me remember.
Proper nutrition, including fluids, may positively affect my memory.
Gender *
Age *
Education Level *
Race/Ethnicity *
Thank you for completing this survey.
Once you complete the post survey at the end of the program your name will be entered into the prize drawing for a crockpot or an air fryer!
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