Alzheimer's Disease

CN012-0024 Clinical Study

Pre-screening - please select your answers

Survey

Selecting an answer means Yes,
leaving the answer unchecked means No.

Does the potential study participant (you or your close relative) have a diagnosis of Alzheimer's disease?

Is the potential study participant between 55-90 years old?

During the course of Alzheimer's disease, does the potential study participant exhibit symptoms or episodes of agitation?

Has the potential study participant experienced a major depressive episode in the past 12 months?

Does the potential study participant have a diagnosis of bipolar disorder, schizophrenia, or schizoaffective disorder?

Contact details

Full name *

Phone *

E-mail *

Age *

City *

Additional informations (optional)

I consent to being contacted by phone and email for the purpose of receiving information about the clinical study and completing the pre-screening process.

I have read the privacy notice regarding the processing of personal data.

M2M Med
ul. Lwowska 34
41-500 Chorzów

Godziny otwarcia:

Poniedziałek - Piątek: 08:00 - 20:00
Sobota: 09:00 - 13:00

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