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Imperial Memory Unit
Alzheimer´s disease treatment trials

Register your interest in trials for the treatment of Alzheimer´s disease

Imperial Memory Unit

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 our clinical trials.

The purpose of this form is for assessing your suitability for our clinical trials trial. We will keep your data for 5 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 or by email on imperial.memory.research@nhs.net.

Contact details and general questions

Please provide your contact details below

Full name Date of birth Email Phone number Sex Female Male How many years were you in education? Are you fluent in English? Yes No How open are you in taking a investigational drug that aims to slow down the progression of Alzheimer´s disease? 1 2 3 4 5 Are you willing to travel to Charing Cross Hospital in Hammersmith once a month? Yes No Maybe Do you have any holidays planned that exceed 2 weeks in the next few years? Yes No Maybe

Study partner

Our trials requires you to have a study partner, this is someone you have weekly contact with. They will need to join you for some visits to answer questionnaires.

Study partner name What is your study partner's relationship to you? Family member Friend Other Do you have at least weekly contact? Either in person or over the phone. Yes No How often does your study partner work? Full time Part time Retired Other If other, please specify

Medical questions

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

GP practice name (this must be your registered NHS GP) Do you have a diagnosis of mild cognitive impairment or Alzheimer’s disease? Mild cognitive impairment due to Alzheimers disease Alzheimers disease Other If other, please specify Do you have any mobility needs? Yes No Do you have severe visual or hearing impairment? Yes No Are you able to have an MRI? Yes No Are you willing to have a PET scan? Yes No Maybe Have you had an amyloid PET scan recently? Yes No Have you had a CSF test recently? Yes No Have you had any issues with blood tests in the past? Yes No Have you donated blood in the last month or will you be donating blood? Yes No Do you have any other neurological conditions (such as Frontotemporal dementia, Lewy body dementia, Cerebro-vascular, Head trauma, etc)? Yes No Have you had any TIAs (mini strokes) or Strokes? Yes No Have you had any seizures? Yes No Have you had any unexplained loss of consciousness? Yes No Do you have any mental illness or symptoms, such as depression, anxiety, schizophrenia, in the last five years? Yes No Do you have any bleeding disorders (e.g. haemophilia)? Yes No Do you have a history of heart disease? Yes No Do you have diabetes? Yes No Do you have hypertension? Yes No Do you have any history of cancer? Yes No Do you have any liver, lung or kidney problems? Yes No Do you have any history of drug or alcohol abuse? Yes No Do you have any major viral infections (HIV, hepatitis etc.)? Yes No Do you have any allergies? Yes No Do you have any planned surgeries? Yes No Do you have any problems with your thyroid function? Yes No Do you have pernicious anaemia (vitamin B12 deficiency)? Yes No Have you participated in a clinical trials before? Yes No Are there any other conditions you would like to make us aware of? Or anything you are awaiting consultation for? 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.

Medications

Please add any regular medications you take, these could be prescribed by your doctor, bought at a pharmacy or from the supermarket.

Do you take any of the following medications for Alzheimer's disease? Donepezil Galantamine Rivastigmine Memantine If you take any of the medications above, are you on a stable dose (if yes, for how long) or are you planning on uptitrating? Do you take any of the following medication, even occasionally? Opioids Morphine codeine oxycodone Benzodiazepine Diazepam flurazepam memantine Antihistamines Do you take any other medications? Please list them below, including the amount and frequency.

About this page

Last updated 23 Feb 2024

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