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. 2021 Feb 14;7(1):e12132. doi: 10.1002/trc2.12132
Question Variable Description Values
1 Name Surname [text]
2 Firstname First name or initials [text]
3 Gender Gender

  1. male

  2. female
4 Birthdate Date of birth [date]
5 Address Address [text]
6 Zipcode Zipcode [text]
7 City City [text]
8 Phone Telephone number [text]
9 E‐mail E‐mail address [text]
10 Signature Signature (type your name) [text]
11 Source How did you hear about us?

  1. TV or radio

  2. My physician

  3. Friends or family

  4. Facebook

  5. Other:
12 Length What is your height? [text] cm
13 Weight How much do you weigh? [text] kg
14 Education

What is your highest level of education?

Comparable to….

  1. Primary education not completed

  2. Primary education completed

  3. Lower secondary education, not completed

  4. Lower secondary education

  5. Upper secondary education

  6. Short‐cycle tertiary education

  7. Tertiary education completed
15 Employment Are you employed (paid labor)?

  1. yes, full time

  2. yes, part time

  3. no, I'm retired

  4. no, I study

  5. no, I'm unemployed

  6. I rather don't like to answer this question
16 Marital status What is your marital status?

  1. single

  2. living together

  3. married

  4. divorced

  5. widowed

  6. other:
17 Housing In what kind of residence do you live?

  1. owner‐occupied or rental house

  2. senior housing (not assisted)

  3. senior housing (assisted)

  4. Other:
18 Health How would you describe your health in general?

  1. excellent

  2. very good

  3. good

  4. moderate

  5. bad
19 Complaints Do you have memory complaints?

  1. no

  2. yes
20 Worries Do you worry about these memory complaints?

  1. no

  2. yes
21 Family diagnosis Have your parents or siblings ever had a diagnosis of dementia?

  1. no (→ Q23)

  2. yes (→ Q22)

  3. I don't know (→ Q23)
22 Family diagnosis = yes What diagnosis do your parents or siblings have?

  1. Alzheimer's disease

  2. Frontotemporal dementia (FTD)

  3. Vascular dementia

  4. Lewy body dementia (LBD)

  5. Mild cognitive impairment (MCI)

  6. Progressive aphasia

  7. Other:
23 Medical Could you indicate for the following diseases if you have them at the moment or have had them in the past?
24 Medical Hypertension (high blood pressure)

  1. no

  2. yes
25 Medical High cholesterol

  1. no

  2. yes
26 Medical Diabetes

  1. no

  2. yes
27 Medical Cardiovascular diseases

  1. no (→ Q29)

  2. yes (→ Q28)
28 Cardiovascular diseases = yes What kind of cardiovascular disease do you have/have you experienced? Several answers possible.

  1. Cardiac arrest

  2. Heart failure

  3. Cardiac arrhythmia (for example atrial fibrillation)

  4. Angina pectoris (chest pain)

  5. Intermittent claudication

  6. Other:
29 Medical Stroke or CVA

  1. no (→ Q31)

  2. yes (→ Q30)
30 Stroke or CVA = yes What kind of stroke or CVA do you have/have you experienced? Several answers possible . →

  1. Cerebral hemorrhage

  2. Cerebral infarct

  3. TIA

  4. Other:
31 Medical Cancer

  1. no (→ Q34)

  2. yes (→ Q32)
32 Cancer = yes What type of cancer do you have/have you experienced? [text]
33 Cancer = yes Did you experience this in the last 5 years?

2. no

1. yes
34 Medical Epilepsy, MS, Parkinson's disease or another neurological condition (other than Alzheimer's disease or other dementia)

  1. no (→ Q37)

  2. yes (→ Q35)
35 Neurological condition = yes Which neurological conditions do you have / have you experienced? Several answers possible.

  1. Alzheimer's disease or another form of dementia (→ Q36)

  2. MCI (→ Q37)

  3. Epilepsy (→ Q37)

  4. Multiple sclerosis (MS) (→ Q37)

  5. Parkinson's disease (→ Q37)

  6. Huntington's disease (→ Q37)

  7. Other: (→ Q37)
36 AD diagnosis = yes What specific diagnosis do you have?

  1. Alzheimer's disease

  2. Frontotemporal dementia (FTD)

  3. Vascular dementia

  4. Lewy body dementia (LBD)

  5. Progressive aphasia

  6. Other:
37 Medical Depression or another psychiatric condition

  1. no (→ Q39)

  2. yes (→ Q38)
38 Psychiatric condition = yes What psychiatric conditions do you have/have you experienced? Several answers possible.

  1. Depression

  2. Anxiety disorder

  3. Schizophrenia

  4. Bipolar disorder/Manic depression

  5. Other:
39 Medication Do you use medication at the moment?

  1. no

  2. yes
40

Medication = 

yes

 Do you use any of the following medication at the moment?

  1. Medication against depression or anxiety, for example citalopram, fluoxetine (Prozac), paroxetine (Seroxat), duloxetine (Cymbalta), amitriptyline, lithium.

  2. Soothing medication/sleep medication, for example oxazepam, diazepam, other benzodiazepinen.

  3. Blood thinner, for example acenocoumarol, sintrom, fenprocoumon (Marcoumar), dabigatran (Pradaxa), rivaroxaban (Xarelto).
  • 4.

    Blood pressure medication, for example hydrochloorthiazide, Zestril (Lisinopril), Coversyl (Perindopril), Selokeen (Metoprolol).

    Platelet inhibitor, for example ascal, carbasalaatcalcium, clopidogrel, Plavix®, Persantin.

  • 5.

    Cholesterol reducing medication, for example simvastatine, ezetimib, atorvastatine, rosuvastatine, pravastatine, bezofribaat.
  • 6.

    Medication for sugar regulation, for example insuline, metformine.

  • 7.

    Antipsychotic, for example Risperidone, Paliperidone, Olanzapine, Quetiapine, Aripiprazol.

  • 8.

    Medication for dementia, for example Donepezil, Rivastigmine, Memantine.
41 Smoking Do you smoke at the moment or have you smoked in the past?

  1. no, I've never smoked

  2. yes, at the moment

  3. yes, in the past

Abbreviations: CVA, cerebrovascular accident; MCI, mild cognitive impairment.