Alzheimer's Study PreScreen
Email address *
Caregiver Information:
Full Name:
Your answer
Relationship to Patient:
Your answer
Telephone Number:
Your answer
Are you able to read, write and understand English?
Will you be available to check in on patient ≥2 hours/day ≥4 days/week?
Will you or another designated caregiver be available to accompany patient to all clinic visits and participate in clinical assessments?
Patient Information:
Full Name:
Your answer
Telephone Number:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Age:
Your answer
Sex:
If Female, Is patient of childbearing potential?
Comment:
Your answer
Allergies:
Your answer
Is patient able to read, write and understand English?
Has patient been diagnosed with mild to moderate Alzheimer’s Disease?
Comment:
Your answer
Is patient currently on medication for Alzheimer's
Medication List:
Please list Name, Dose, Frequency and Length of time on each medication for Alzheimer's Disease.
Your answer
Your answer
Your answer
Your answer
Has the patient suffered from a cortical stroke within the preceding 2 years?
Has patient been showing signs of delirium?
Has patient been diagnosed with any other psychiatric illnesses other than Alzheimer’s?
Comment:
Your answer
Does patient have any conditions that would contraindicate an MRI, such as the presence of metallic objects in the eye, skin, or heart?
Does patient have a history or malignant cancer within the last 5 years?
Comment:
Your answer
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