Join Alzheimer’s research study

Join Alzheimer’s research study

Please answer all the questions to join this research study. Your answers are kept confidential and will not be shared with anyone except the research team.
1. Are you answering for yourself or on behalf of someone else? *

I’m answering for myself I’m answering for someone else
1.1 Your name

First Name Last Name
1.2 Your relationship with the participant:
1.3 Your Email *
example@example.com
Please consider all mentions of “you” and “your” to refer to the participant in all questions that follow from now on.
2. Name *

First Name Last Name
3. Email *
example@example.com
4. How did you hear about this study? Please provide details such as in which language, where and when if possible.
Details:
How did you hear about this study? Please provide details such as in which language, where and when if possible.
5. Do you live in the United States or Canada? *

United States Canada
6. Do you have any of the following ancestral backgrounds? (select all that apply) *

Chinese Korean Vietnamese
7. Is your mother Chinese, Korean or Vietnamese? (select all that apply) *

Chinese Korean Vietnamese
8. Is your father Chinese, Korean or Vietnamese? (select all that apply) *

Chinese Korean Vietnamese
9. Are you 60 years or older? *

Yes No
10. Do you have memory problems or other changes in how your brain works? *

Yes No
If Yes, please specify.
10.1 Are you diagnosed with Alzheimer’s disease?

Yes No
11. Are you willing to answer questions about your personal history and have your memory tested? *

Yes No
12. Would you be willing to give at least one blood or saliva sample for genetic testing, although your results will not be reported back to you? *

Yes No
Result *
source
area
Phone appointment

Thank you for completing the questionnaire. You appear to pass all study criteria. As a last step, the research team would like to speak with you on the phone. You will get the opportunity to learn more about the study and ask questions before deciding to join.
Phone Number *

Area Code Phone Number
Preferred time(s) to be contacted:

9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM
Wayturn contact email
Should be Empty:

Join Alzheimer’s research study

Phone appointment