Bangkok International Hospital (Brain x Bone)
Part 1
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Yes/Have
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No/Do Not Have
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Notes
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| 1. Female |
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| 2. Have high blood pressure |
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| 3. Have diabetes |
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| 4. Have high cholesterol |
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| 5. Have cerebrovascular disease |
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| 6. Have had a brain injury |
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| 7. Have a family history of Alzheimer’s disease in direct relatives |
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| 8. (If there is a family history of Alzheimer’s disease in direct relatives) Symptoms occur at age |
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| 9. No longer working |
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| 10. Vegetarian/Do not eat meat |
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| 11. Have thyroid disease |
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| 12. Have symptoms of Parkinson’s disease |
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Part 2 Do you have these symptoms?
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Yes/Have
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No/Do Not Have
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Notes
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| 1. Forgetfulness, unable to find things |
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| 2. Annoyingly repetitive questioning |
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| 3. Getting lost in familiar places |
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| 4. Forgetting important appointments or recent significant events |
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| 5. Having problems with planning |
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| 6. Having social interaction problems |
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| 7. Having trouble naming objects or people |
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| 8. Forgetfulness affecting daily life |
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| 9. Impaired decision making |
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| 10. Using sleeping pills |
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| 11. Having problems sleeping |
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| 12. Having changes in behavior |
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If you answered Yes/Have in at least 1 item in Part 1 and Yes/Have in at least 1 item in Part 2, you should consult a doctor
