Patient Form – Headlands Research EMA

Demographics

Name(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

What is your preferred method of contact?(Required)

Our office is located in Plymouth, MA. Would regular travelling to Plymouth for study visits be an issue for you? (distance, snowbird, etc.)(Required)

Medical History

Do you see / Have you seen a neurologist before?(Required)

Have you been diagnosed with any of the following neurological conditions? Check all that apply.(Required)

Mild Cognitive Impairment

Alzheimer’s Disease

Dementia with Lewy Bodies

Other Dementias

Parkinson’s Disease

Progressive Supranuclear Palsy

None of These

Do you have any family history of dementia or Alzheimer’s Disease?(Required)

Do you currently have, or have you experienced any of the following conditions? Check all that apply.(Required)

Please provide a list of your current medications including over the counter vitamins, supplements and pain relievers. Be sure to include the name of the medication, the dosage that you take, the frequency with which you take this medication and the method through which you take it (by mouth, inhalation, injection, etc.)(Required)

Additional Information

Please let us know if there is anything that you would like our team to provide additional information on when you are contacted.(Required)

Consent for Storage of Information

Do you consent to having the self-reported information from this form stored in our clinical trials database to be reviewed for possible participation in research studies now and in the future?(Required)

If no, our team will still contact you regarding your responses, but the information will not be stored for future review.

Phone

This field is for validation purposes and should be left unchanged.