$200 Memory Loss Study - In Person - Ft. Lauderdale, Florida
Have you ever participated in a clinical trial in relations to Memory Loss? Are experiencing memory loss or have Mild Cognitive Impairment or you have been diagnosed with Pre-Alzheimer’s Disease/Early Alzheimer’s? If you answered yes then you would qualify to participate

Fill out the questionnaire and we will contact you for scheduling.

Elite Market Research Team Nationwide
www.elitemarketresearchteamnationwide.net

First Name & Last Name *
BOTH ARE REQUIRED
Your answer
Phone Number *
Your answer
Email address *
Your answer
Q1. Gender *
Q2. Age *
Your answer
Q3a. Do you work in any of the following areas? *
Required
Q4. Are you, yourself, currently scheduled to participate in any marketing research studies? *
Q5. Have you noticed that your memory is not what it used to be? *
Q6. Do you find that it interferes with your daily activities such as finding belongings, keeping appointments, getting around? *
Q7. Over the last 6 months, has your memory......: *
Q8. Have you mentioned your memory concerns to your physician? *
THIS QUESTION IS FOR THOSE THAT MENTION IT TO THEIR DOCTOR... IF YOU DID NOT REPLY N/A
Q9. What did your doctor say you had? *
Q10. How long ago was the visit when you had this discussion? *
Q11. Have you been diagnosed with any of the following ailments? Please select all that apply. *
Required
Q12. Have you ever participated in a clinical trial? *
Q13. Are you currently participating in a clinical trial? *
Q14. When did the clinical trial you participated in end? *
Required
Q15. Was the clinical trial in relation to Memory Loss? *
Q16. How many estimated hours per week are you on the internet? This includes time on a computer, tablet/iPad, and smart phone. *
Q17. What types of tasks do you use the internet for? *
Required
What is your ethinicity *
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