Imperial College Stem Cell Therapy Questionnaire - Alzheimer's Disease

1. About You

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Before finding out what you know about stem cell therapy, we'd like to know a bit about you. All data collected here is anonymous and securely stored.

1. Please enter your date of birth.

	DD		MM		YYYY
-	Please enter your date of birth. - Day	/	Month	/	Year

2. Are you male or female?

Are you male or female? Female

Male

3. What is your ethnicity?

What is your ethnicity?

If other ethnic group has been selected, please specify

4. Which town/city do you live in?

Which town/city do you live in? City/Town:
Country:

5. Approximately how long have you been living with Alzheimer's Disease?

Approximately how long have you been living with Alzheimer's Disease? Less than a year

1-2 years

3-5 years

6-10 years

Longer than 10 years

N/A I'm answering on behalf of someone with Alzheimer's Disease

If answering on behalf of someone else, what is your relationship to the person with Alzheimer's Disease?

6. How much does having Alzheimer's Disease impact on your quality of life?

How much does having Alzheimer's Disease impact on your quality of life? Not at all

A little

Moderately

Quite a lot

Severely

7. How often does having Alzheimer's Disease affect your life?

How often does having Alzheimer's Disease affect your life? All the time

Daily

Weekly

Monthly

Less than monthly

8. Do you suffer from any other medical conditions?

Do you suffer from any other medical conditions?

If yes, please give details of these conditions.

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