We appreciate your interest in learning more about the research studies and services we offer at the University of Kansas Alzheimer's Disease Center. Connecting with us is an important step toward us finding better ways to prevent and treat Alzheimer's disease and other dementias. Complete the form below with your contact information and research interests and a member of our team will contact you to discuss further. (Research opportunities are available for both people with and without diagnosed memory changes.) Please note that the information you provide here is collected and kept as part of our process to best match you to the services and studies offered at the center.
Today M-D-Y
Would you like yourself or a loved one to be considered for clinical research at the KU Alzheimer's Disease Center?
Self
Loved one
What is your relationship to the participant?
spouse child parent sibling other
Please specify your relationship to the participant
Point of Contact First & Last Name
Your first and last name
Your email
Point of Contact Phone number
Your Phone Number
Point of Contact Primary speaking language
English
Spanish
Other
Other primary speaking language
Are you interested in a specific research study that you recently became aware of?
Yes
No
What is the name of the research study you are interested in?
What types of research studies are you interested in?
Investigational Medicine/Supplement Trials
Exercise, Nutrition and Lifestyle Intervention Trials
Discovery and Innovation Studies
Other
Investigational Medicine/Supplement Trials
Exercise, Nutrition and Lifestyle Intervention Trials
Discovery and Innovation Studies
Other
What other type(s) of research are you interested in?
What most recently caused you to reach out to the KU Alzheimer's Disease Center with an interest in participating in research?
Family or Friend Health care professional (MD, RN, etc.) Newspaper or magazine TV or Radio Website/Internet Social Media (Facebook, Twitter, etc.) Brochure, flyer, poster Public presentation/event (in-person) Mail/Letter or email MyAlliance Sponsor portal Webinar
First & Last Name
* must provide value
If you are completing this on behalf of someone else, please list their name here.
If you are completing this on behalf of someone else, please list their preferred name here.
Today M-D-Y If you are completing this on behalf of someone else, please list their date of birth here.
View equation If you are completing this on behalf of someone else, please list your loved one's zip code here.
If you are completing this on behalf of someone else, please list your loved one's email here. If you do not want us to contact them at all (and only contact you) please leave this blank.
Phone number
* must provide value
If you are completing this on behalf of someone else, please list your loved one's phone number here. If you do not want us to contact them at all (and only contact you) please enter (555)555-5555.
Primary speaking language of participant
English
Spanish
Other
If you are completing this on behalf of someone else, please list your loved one's primary language here
Other primary speaking language
Do you feel that you (they) are experiencing any memory or thinking changes?
Yes
No
Maybe/I don't know
Please indicate what changes in memory, thinking or behavior are being experienced, if any. (click all that apply)
Decreased or poor judgment
Less interest in hobbies/activities
Repeating the same things over and over (questions, stories, or statements)
Trouble learning how to use a tool appliance or gadget (e.g. computer, microwave, remote control)
Confusion with time or place
Difficulty handling financial affairs? (e.g., balancing checkbook or paying bills)
Trouble remembering appointments
Daily problems with memory or difficulty completing familiar task
Decreased or poor judgment
Less interest in hobbies/activities
Repeating the same things over and over (questions, stories, or statements)
Trouble learning how to use a tool appliance or gadget (e.g. computer, microwave, remote control)
Confusion with time or place
Difficulty handling financial affairs? (e.g., balancing checkbook or paying bills)
Trouble remembering appointments
Daily problems with memory or difficulty completing familiar task
Have these concerns been mentioned to a doctor?
Yes
No
Have you (they) been diagnosed with a memory impairment?
Yes
No
Are you (they) currently taking prescribed memory medications?
Yes
No
Other notes, comments or concerns
Thank you! A member of our research team will contact you as soon as possible to discuss the current research opportunities available.
**Please note: Many of our studies limit participants to active participation in only one study at a time. If you are already enrolled in one of our research studies, we encourage you to first contact your study coordinator to discuss further, prior to completing this form. Thank you for understanding.**
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