Cognitive Questionnaire

 

 

The ARDS Support Center has heard from many ARDS survivors who have experienced and have questions about cognitive changes noted after surviving ARDS. Some of these conditions are short term memory loss, difficulty in concentration, depression, anxiety and difficulty in performing normal everyday functions. There is a great need for more research and the medical community is devoting increasing attention to these post-ARDS cognitive problems.

 

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Section A

Tell us how to get in touch with you:

Name
E-mail
Confirm E-mail
Telephone

Section B

1.) Do you have problems with loss of memory? If so, please describe the problems.

Yes
No



2.) Do you have trouble concentrating?

Yes
No

3.) Do you have trouble organizing your day?

Yes
No

4.) Is it difficult to pay close attention to TV?

Yes
No

5.) Are you able to comprehend what you read?

Yes
No

6.) Do you find yourself having to go back and re-read paragraphs that you just read?

Yes
No

7.) Do you lose your place while reading?

Yes
No

8.) Do you have problems with basic self-care?

Yes
No

9.) Do you have trouble driving?

Yes
No

10.) Do you have problems with community based mobility skills, i.e. walking, attending meetings and understanding what was said, etc.?

Yes
No

11.) Do you have difficulty with fine motor skills?

Yes
No

12.) Do you feel that your judgment is impaired?

Yes
No

13.) Do you feel that you have poor safety awareness?

Yes
No

14.) Do you find yourself suddenly being impulsive?

Yes
No

15.) Are you having problems with sleep/wake cycles? If so, please describe.

Yes
No


16.) Have you noticed any changes in your personality?

Yes
No

17.) Please tell us about any other areas in your mental thinking/anxiety/emotions that you are having problems with.



 

This release hereby authorizes ARDS Support Center, Inc., or their agents, to examine, make copies of, and/or share any and all medical information with the ARDS Support Center Board of Medical Advisors that I have supplied on this questionnaire. 

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Thank you for taking the time to complete the survey !


 

Copyright 2000 ASC. All rights reserved.
Revised: October 25, 2003