Language
English (US)
Chinese (Simplified Han)
Chinese (Traditional Han)
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.
Social Media.
Community Service Center.
Conference, Community Forum, seminar or Workshop.
Email through a listserv.
At a health care provider’s office.
Radio.
TV.
Newspaper.
Family member.
Friend.
Neighbor.
Other.
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
Other
6. Do you have any of the following ancestral backgrounds? (select all that apply)
*
Chinese
Korean
Vietnamese
Other
7. Is your mother Chinese, Korean or Vietnamese? (select all that apply)
*
Chinese
Korean
Vietnamese
Other
8. Is your father Chinese, Korean or Vietnamese? (select all that apply)
*
Chinese
Korean
Vietnamese
Other
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
*
Pass
Fail
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
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