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Imperial Memory Unit
Preventative trials

Register your interest for preventative trials

Imperial Memory Unit

Thank you for your interest in clinical trials at the Imperial Memory Unit, Charing Cross Hospital.

If you are interested in screening for one of our clinical trials, please fill out the form below and one of our team will be in touch. You are not required to answer all the questions, though any details you are happy to provide will help us better assess your suitability for participating in a clinical trial.

We will keep your data for five years, and it will not be shared with any third parties. If you are not suitable for our currently recruiting trials, we might contact you in the future about new trials, which you may be suitable for depending on your answers to this form. If you do not want us to keep your information, please let us know by contacting us on the details below.

You can contact us by phone on 020 3311 5228, email on imperial.memory.research@nhs.net

Contact details and general questions

Please provide your contact details below

Full name Date of birth If you are under the age of 65, do you have a first degree relative who experienced memory symptoms before the age of 75? Yes No Sex Male Female Are you willing to travel to Charing Cross Hospital in Hammersmith every two or four weeks? Yes No Email Phone number How open are you in taking a investigational drug (such as Lecanemab) that aims to prevent Alzheimer´s disease? 1 2 3 4 5 How did you find out about us? Social media such as Facebook Joint dementia research Email Friends and family Other If other, please specify

Study partner

Our trials requires you to have a study partner, this is someone you have weekly contact with and who knows you well. They will need to join you for some visits (average of eight visits over four years) to answer some questionnaires about you and your health.

Do you know someone who could act as your study partner? Yes No Maybe What is your study partner's relationship to you? Family member Friend Other

Medical questions

These questions are to see if there is anything in your medical history that would exclude you from any of our trials.

Have you gone to your GP to discuss any memory concerns? Yes No Are you able to have an MRI? Yes No Are you willing to have a PET scan? Yes No Maybe Do you have a history within the past two years of psychiatric diagnosis or symptoms (eg, hallucinations, major depression, or delusions) Yes No Do you have any history of cancer in the last five years? Yes No Do you have a history of heart disease? Yes No Have you participated in clinical trials before? Yes No If you have replied yes to any of the questions above (excluding questions about your ability to have specific scans), please provide details here. Do you take any of the following medications? Any acetylcholinesterase AChE inhibitors such as galantamine or donepezil these are used to treat Al Any anticoagulants such as rivaroxaban or apixaban Is there anything else in your medical history you would like make us aware of?

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Last updated 2 May 2024

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