Memesto Pilot Testing

Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which of the following describes you? *

Professional Caregiver

Family Caregiver

An individual with some level of dementia

If you are a family caregiver, please check all that apply:

I live with the person with dementia.

I visit the person with dementia every day.

I visit the person with dementia 1-3 times per week.

I do not live in the same city as the person with dementia.

If you are a family caregiver, has your loved one exhibited signs of agitation?

Yes

No

If so, please rate the frequency of agitation by choosing one of the following:

Rarely: once a week or less

Regularly: 3-4 times a week

Often: daily and sometimes multiple times per day

If you’re a family caregiver, has your loved one with dementia been prescribed medications to help calm them?

Yes

No

What is the frequency of the prescribed medications?

Daily

Only as needed for calming