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Virginia Memory Project (Demographics)

Please complete the survey below. Your information is confidential, and your answers help advocates understand how better to support Virginians living with neurodegenerative disorders and their caregivers You can also ask to be connected to resources in Virginia for memory, brain health, and caregiving.

For any questions or concerns, please get in touch with Project Director Annie Rhodes at 804-821-1830 at Virginia Commonwealth Department of Gerontology and Virginia Center on Aging at rhodesas2@vcu.edu.

The Virginia Memory Project is a responsive registry with comprehensive brain health and caregivers services. It is supported by the Virginia Department of Health, Office of Family Health Services. #709CF220023.

FYI:

The Virginia Memory Project is a brief survey available to all Virginians. Your answers are confidential.
You do not need to have a brain health, memory, neurodegenerative, or caregiving concern to take this survey.
You can request a follow-up referral from the Virginia Memory Project
If you provide your email address, resources will be sent to you via email, which you may find helpful

Today's Date

M-D-Y

Do you live in Virginia?

Yes

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How did you hear about The Virginia Memory Project?

In an online newsletter

On social media

At an event

My healthcare provider encouraged me to enroll

From the health department or another agency

At my faith community or other community center

From the newspaper or other local media

Other

What is your date of birth?

You can use the calendar icon to the left to pick out your birthdate OR you can enter it in manually

Example

01-01-1959

M-D-Y

Age

View equation

What is your street name?

Which one or more of the following would you say is your race and ethnicity? You are also welcome to self describe below

(Check all that apply)

White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Middle Eastern/North African
Hispanic/Latino/a/x
Don't know/ Not sure
Prefer not to Answer

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Middle Eastern/North African

Hispanic/Latino/a/x

Other [specify]

Don't know / Not sure

Prefer not to answer

Other Racial Identity

Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

Would you say...?

Yes, now on active duty

Yes, on active duty during the last 12 months, but not now

Yes, on active duty in the past, but not during the last 12 months

No, training for Reserves or National Guard only

No, never served in the military

Don't know / Not sure

Decline to answer

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What best describes your marital status

Are you...?

Married

Divorced

Widowed

Separated

Never married

A member of an unmarried couple

Prefer not to answer

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How many children less than 18 years of age live in your household?

Choose to enter the number of children

None

Prefer not to answer

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Number of children

What best describes your educational attainment?

Never attended school or only attended kindergarten

Grades 1 through 8 (Elementary)

Grades 9 through 11 (Some high school)

Grade 12 or GED (High school graduate)

College 1 year to 3 years (Some college or technical school)

College 4 years or more (College graduate)

Decline to answer

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Are you currently...?

Employed for wages

Self-employed

Out of work for more than 1 year

Out of work for less than 1 year

A Homemaker

A Student

Retired

Unable to work

Decline to answer

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What is your annual household income from all sources?

Less than $10,000

Less than $15,000

Less than $20, 000

Less than $25,000

Less than $35,000

Less than $50,000

Less than $75,000

My income is more than $75,000

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Please enter your zip code

What is your gender identiy?

Male

Female

Other [specify below]

Prefer not to answer

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Other [specify]

Have you been told by a healthcare provider that you have a major health problem or long-term illness?

Select all that apply.

Arthritis/Rheumatism

Asthma

Cancer

Diabetes

Heart Disease

Hypertension/High Blood Pressure

Lung Disease/Emphysema

Osteoporosis

Parkinson's Disease

Stroke

Eye/Vision Problem (blindness)

Hearing Problems (deafness)

Multiple Sclerosis (MS)

Spinal Cord Injury

Traumatic Brain Injury (TBI)

Alzheimer's Disease or Dementia

Attention-Deficit Hyperactivity Disorder (ADHD)

Learning Disabilities (LD)

Cerebral Palsy (CP)

Down's Syndrome

Other developmental disability (e.g., spinal bifida, muscular dystrophy, fragile X)

Anxiety

Depression

HIV/AIDS

Substance Use Disorder

Other

Not Applicable

No Diagnosis

The Virginia Memory Project uses responses to improve programming and advocate for resources across Virginia for people with Brain Health Concerns, Caregiving Questions, Memory Loss, and Neurodegenerative Disorders.

When you let us know what you need, you help us connect you with resources now and advocate for the resources required in Virginia. While we have listed some common requests here, please also contribute your ideas.

If you leave your contact information, we will also send you resources.

You can remain anonymous.

Select all that apply:

I would like someone to screen my memory

I would education about brain health

I would like a professional to help me monitor my memory and look for changes over time.

I need a care coordinator or case manager to help access resources and programs

I am a caregiver, and I need caregiving-specific services

I would like to learn more about Advance Care Planning and legal documents such as: Power of Attorney or a Living Will, and I may need some help completing these documents

I would like to know about local community-based programs and how to access them

I would like tips on communicating with my healthcare provider

I would like someone to help me enroll in clinical trials or other research for memory loss

I would like help finding a healthcare provider, such as: A Primary Care Doctor or a Neurologist or a Memory Specialist

Other/Not Listed (List Below)

No Services are Needed

If you selected "Other," Let us know what you are looking for or what would support your wellbeing

We will be looking to find an appropriate referral for you.

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Would you like information about the Virginia Memory Project, Caregiving or Brain Health to educate a group at your religious home or a community center?

*We typically can provide community education at no charge.

Yes

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Please provide an email address of whomever we should reach out to so that we can reach out about coordinating an educational event for your group!

Thank you!

Would you like to be invited to live educational events like our "Caregiver Conversations" program?

The VMP partners with various community organizations and presents live and virtual events on dementia, caregiving, brain health, and other topics. If you enter your email address below, we will be sure you are invited to these events.

Yes

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Please provide an email address so we can add you to our invite list for online caregiver educational sessions!

Please leave your contact information if you want specific information or services in your area.
If you do not want to be contacted, please check "No" and continue the survey.

The next questions will be about Memory Loss

Yes

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What is your name?

What is ______'s email address?

What is a good phone number for ______?

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.