Inquire Today Inquire Today for a FREE Clinical Trial Evaluation! (Phone Screener) Inquire Today for a FREE Clinical Trial Evaluation! (Phone Screener) First Name * Last Name * Phone Number * Email Address * Home Address Are you calling for yourself? * Yes, I am calling for myself No, I am calling for someone I know If NO, who are you calling for? * What prompted you to contact us today? What age are you or is the person you are contacting us about? * Date of birth * Have you been diagnosed with a memory disorder? Yes No What is the diagnosis? * Who diagnosed you? * Are you taking any medications for this diagnosis? * Yes No Please list medication names/date started * Do you know your MMSE score? * Yes No What is your MMSE score? * Are you currently participating in any other clinical trials? * Yes No Have you ever participated in clinical trials? * Yes No Do you have a pacemaker? * Yes No Have you ever had a stroke? * Yes No Have you ever been diagnosed with any type of cancer? * Yes No When was the diagnosis made? * How long have you been in remission? * What type of cancer? * Do you have any other neurological disorders? * Yes No If you have any other neurological disorders, please list them here: * Do you take any anti-depressants? * Yes No If you take anti-depressants, please list them here: * Do you have a caregiver/study partner available for visits? * Yes No Do you plan to travel for long periods of time in the near future? * Yes No Have you had an MRI/CT/PET scan in the past 12 months? * Yes No Do you have any questions or comments? Please note them here: Captcha Submit
