. TRAILBLAZER-ALZ 2

See If You May Pre-Qualify

Who are you taking this questionnaire for?  




1. What is your zip code?
2. What is your date of birth?
Month Day Year
3. Please select your gender:

4. Have you been diagnosed with either Mild Cognitive Impairment due to Alzheimer’s Disease or Mild Alzheimer’s Disease Dementia?


5. Do you have any current neurological diseases, such as Parkinson’s disease or epilepsy?


6. Do you currently have a cardiac pacemaker/defibrillator or have any metallic implants in the brain, eye, or ears?


7. If asked to do so, would you be willing to have an MRI scan and PET scan?


8. This study requires a study partner such as a relative, spouse, friend, or caregiver that can help the study participant meet study requirements.

The study partner does not have to live with the participant but must spend enough time with the participant (at least 10 hours a week) and be available to provide follow-up information on the participant throughout the study. The time spent with the participant doesn’t always have to be in person. The study partner must be available to attend certain study appointments with the participant, including the initial appointment. The study center can review this in more detail if you pre-qualify.

Do you have a study partner that will meet these requirements?


9. How did you hear about us?