HOME
ABOUT THE STUDY
ABOUT AGITATION
PREQUALIFY
STUDY LOCATIONS
FAQ's
Eligibility Questionnaire
To determine if you prequalify for this clinical research study, we have some questions for you about you or your loved one's health history and present condition. You do not have to answer all of the questions, but if you do not answer all of the questions, we will not be able to assess you or your loved one's initial prequalification for participation. We respect and protect your privacy. Review our privacy policy at:
agitationalzheimersstudy.com/PrivacyPolicy.html
What is your Postal Code?
Where did you learn about this research study?
--Select--
TV
Radio
Newspaper
Mail Piece
Facebook
Google
Other Website
Flyer/Brochure
Word of Mouth
Other
If other, please specify
Are you completing this form for yourself or someone else?
--Select--
Self
Someone Else
Do you have permission to submit the answers to these questions on behalf of the patient?
--Select--
Yes
No
I agree to the
Privacy Policy.
I am also indicating that I understand my rights and responsibilities as a user of this site and I consent to the information being used as described above.
