Have you stayed in any of the following in the last 6 months?
(Check all that apply or if none, click next)

Do you need someone to help you with any of the following?
(Check all that apply or if none, click next)

Do you have difficulty remembering things such as paying your bills each month?

• Yes
• No

Have you ever been diagnosed with dementia or Alzheimer's?

• Yes
• No

Have you ever wandered or driven away from a known location and felt disoriented or lost?

• Yes
• No