AZT-001 Cognite Trial Pre-Qualification

Where did you learn about this clinical trial?*

What is your zip/postal code?

ZIP / Postal Code

What is your first and last name?*

First Last

What is the best number at which the study coordinator may reach you?*

What is the best number at which the study coordinator may text you?*

What is your email address?*

What is your preferred form of contact?*

What is your gender?*

[Female Only] Are you pregnant, planning a pregnancy, or breastfeeding?*

Are you between the ages of 55 to 79 years old?*

Have you experienced memory problems, or been told by someone close to you that they are concerned with your memory?*

Have you previously been diagnosed with any form of dementia?*

Have you been told that you have Parkinson’s disease, multiple sclerosis, or other neurological disease?*

Have you been diagnosed with schizophrenia or bipolar disorder?*

Do you have a history of alcohol or substance abuse or dependence within the past 3 years?*

Do you have unconrolled chronic asthma or any clinically significan respiratory disorders that may cause difficulty taking inhaled drugs?*

Are you generally in good health?*

Do you take daily high dose antiinflammatory drugs such as Advil, Motrin, Aleve, or aspirin for athritis or for other reasons?*

Are you currently in any other clinical trial?*

NOTE: Pre-Qualification Questions are not saved or submitted to study locations. ONLY contact information is submitted.

Email to send contact info to - HIDDEN FIELD*