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 myselfNo, 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? YesNo What is the diagnosis? * Who diagnosed you? * Are you taking any medications for this diagnosis? * YesNo Please list medication names/date started * Do you know your MMSE score? * YesNo What is your MMSE score? * Are you currently participating in any other clinical trials? * YesNo Have you ever participated in clinical trials? * YesNo Do you have a pacemaker? * YesNo Have you ever had a stroke? * YesNo Have you ever been diagnosed with any type of cancer? * YesNo When was the diagnosis made? * How long have you been in remission? * What type of cancer? * Do you have any other neurological disorders? * YesNo If you have any other neurological disorders, please list them here: * Do you take any anti-depressants? * YesNo If you take anti-depressants, please list them here: * Do you have a caregiver/study partner available for visits? * YesNo Do you plan to travel for long periods of time in the near future? * YesNo Have you had an MRI/CT/PET scan in the past 12 months? * YesNo Do you have any questions or comments? Please note them here: By selecting this checkbox, I consent to receiving text messages from The Alzheimer's Disease Research Center. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. Message frequency varies per user. Text HELP for help or call us at 518-426-0575. Reply STOP to unsubscribe. Please refer to our Privacy Policy and Terms and Conditions. * Yes Privacy Policy, Terms and Conditions Captcha Submit If you are human, leave this field blank.