Take a few minutes to answer these few questions in order for us to determine whether you might be a candidate for one of our trials

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1. What is your relationship to the patient?

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2. How long has the patient been diagnosed with Probable Alzheimer's Disease, and would you say the memory loss could be classified as mild, moderate or severe?

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3. Is the patient currently living with cancer or has had cancer in the past?

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4. Has the patient ever had a stroke or a major head injury?

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5. Please list all medications the patient is currently taking.

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Please provide your answers to these five questions below, as well as a good contact number where you can be reached so that we may call you regarding your participation in one of our studies.

name

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email address

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contact phone number

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patient information