Agitation in Alzheimer’s Disease Studies

Agitation in Alzheimer’s Disease Clinical Trials

Help us research potential new treatment that may help agitation in Alzheimer’s Disease patients

ANSWER A FEW QUESTIONS TO START!

We’re looking for adults to take part in clinical trials assessing investigational medications for Alzheimer's-related restlessness, irritability, and distress.

Study benefits include:

Compensation may be available.
Studies are supervised by a specialized medical team.
Study-related care and investigational medications are provided at no cost.
No insurance is required.

Clinical trial participants must:

Be 55-90 years old
Be diagnosed with symptoms of Alzheimer’s Disease at least 12 months ago
Have had agitation symptoms for at least two weeks

What happens if I fill out the questionnaire?

If you or your loved one qualify, you will be contacted by study staff who can answer your questions before you decide to participate. If after talking to the study coordinator you decide to participate in the studies, you will be asked to read and sign a consent form which provides detailed information including your rights, risks, benefits, and requirements of the studies.

Fields marked with an * are required.

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible. To opt out, reply “STOP” or similar words. Message and data rates may apply. By clicking ”Yes”, you also agree to our SMS Terms. *

yes no

Who are you interested in this study for (relationship to the potential study participant)? *

Myself

My Spouse

My Parent

A loved one

Other

First Name of Potential Participant *

Last Name of Potential Participant *

Phone Number of Potential Participant *

Email of Potential Participant *

Date of Birth MM/DD/YYYY of Potential Participant *

Zip Code of Potential Participant *

What is the assigned gender at birth of the Potential Participant? *

Male

Female

Prefer not to say

Has the Potential Participant been experiencing memory or thinking problems for over a year in a way that seems consistent with Alzheimer’s Disease? *

Yes No Unsure

Has the Potential Participant been experiencing any of the following symptoms for two weeks or longer? *
Please select all that apply.

Excessive movement (pacing/ rocking/ gesturing/ pointing fingers/ restlessness)

Verbal aggression (yelling/ speaking in an excessively loud voice/ using profanity/ screaming/ shouting)

Physical aggression (grabbing/ shoving/ resisting/ hitting others/ kicking objects or people/ scratching/ biting/ throwing objects/ hitting self/ slamming doors/ tearing things/ destroying property

None of the above

Unsure

Has the Potential Participant been diagnosed by a doctor with any of the following conditions? *
Please select all that apply.

Mixed dementia – Dementia from more than one cause

Vascular dementia – Dementia caused by brain damage

Dementia with Lewy bodies (DLB)

Parkinson’s disease dementia

Frontotemporal dementia (FTD) – Dementia with changes to personality/ behavior/ and language

Schizophrenia

Schizoaffective disorder

Bipolar I disorder

Bipolar II disorder

Human immunodeficiency virus (HIV)

Active Hepatitis B

Active Hepatitis C

None of the above

Unsure

Has the Potential Participant been diagnosed by a doctor with any other medical conditions? * 
(For Example: Hemorrhage, epilepsy, seizures, hepatitis, heart attack)
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Is the Potential Participant taking any medications or treatments for Alzheimer’s or other health conditions? *
(For Example: amlodipine, alprazolam, amitriptyline, metformin)
Please list them below or type ‘none’.

Does the Potential Participant live in a private home with family members or other individuals, or in a care facility? *

Home with family members or others

Care Facility

None of the above

How long has the Potential Participant been in this living situation for? *

Less than 1 month

More than 1 month

Does the Potential Participant have a caregiver, family member, or study partner that will accompany them on all study visits? *
A study partner is someone who observes and interacts with the Potential Participant at minimum 2 hours/day for at least 4 days/week. This can include a caregiver, family member, or close friend.

Yes No

Please, select the height of the Potential Participant from the dropdown below. *

How much does the Potential Participant weigh in Lbs (pounds)? *

Which racial or ethnic group(s) does the Potential Participant identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc)

Another race or ethnicity

I prefer not to answer

Does the Potential Participant identify as Hispanic? *

Yes No

First Name of caregiver/study partner to contact *

Last Name of caregiver/study partner to contact *

Phone Number of caregiver/study partner to contact *

Email of caregiver/study partner to contact *

What is the best day/time to reach you via telephone (we know you are busy)? *

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

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