SEE IF YOU MAY PREQUALIFY

Volunteering for a clinical research study may be the first step to learning about your brain health and addressing symptoms of early Alzheimer’s disease.

Find out in minutes if you might pre-qualify to participate in a research study for an investigational drug to treat Alzheimer’s disease by answering the questions below*.

None of the questions are mandatory and you do not have to answer any question(s) that you do not want to answer. Your answers will only be used to help decide if you may be eligible to participate in Alzheimer’s research.

Authorized to Leave a Detailed Voice Mail?
Address
Is this the Participant’s full-time residence?
If completing this form on behalf of someone else, please indicate your name and your relationship to the participant (i.e. spouse, adult child, etc.)
Name
User Agreement
If you have any questions about this form or how your answers will be used, please contact Ashlyn Edward, site contact for the study from Banner Alzheimer’s Institute at (520) 694-7021.

Study Participant Medical History

Do You Have a Diagnosis of:
MM slash DD slash YYYY
Have you had memory decline with gradual onset and slow progression over the last 6 months?
Do you have someone who could be a research study partner and attend regular visits with you and spends/could spend at least 10 hours/week with you?
Are you able and willing to attend regular research study visits approximately every 4 weeks for approximately 2.5 years?
Do you currently have cancer or a history of cancer?
MM slash DD slash YYYY
Do you have a history of depression, bipolar disorder, schizophrenia, anxiety or other mental health illness?
Do you have a heart or respiratory condition? (Examples include unstable HTN, chronic health failure, COPD, emphysema, etc.)
Do you have a history of stroke, neurological problems, or head trauma with loss of consciousness?
Do you have any mental health illness and/or medical condition not currently controlled by medication?
Do you get claustrophobia, have metal in your body (e.g., a pacemaker, metal implant, plates, etc) or have any other reason why you may not be able to endure an MRI or PET scan?
Please rate your CURRENT level of difficulty performing the following everyday tasks by checking the most accurate answer:
Remembering a few shopping items
Remembering things that happened recently, such as outings within the past few weeks, events in the recent news, etc.
Recalling conversations a few days after they happened.
Remembering where you placed objects.

Participant’s Medication List

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

Study Partner Information (if available)

Do you/can you spend at least 10 hours a week with the study Participant?
Years
Hours

If this form is completed by the study participant, please check boxes below to submit:

Consent
Consent

If this form is completed by the study partner, please check boxes below to submit:

Consent
Consent