Where did you learn about this clinical trial?*TVRadioPrintMail PieceFacebookOther WebsiteFlyer/BrochureWord of MouthOtherWhat 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?*EmailPhoneTextWhat is your gender?*MaleFemale[Female Only] Are you pregnant, planning a pregnancy, or breastfeeding?*YesNoAre you between the ages of 55 to 79 years old?*YesNoHave you experienced memory problems, or been told by someone close to you that they are concerned with your memory?*YesNoHave you previously been diagnosed with any form of dementia?*YesNoHave you been told that you have Parkinson’s disease, multiple sclerosis, or other neurological disease?*YesNoHave you been diagnosed with schizophrenia or bipolar disorder?*YesNoDo you have a history of alcohol or substance abuse or dependence within the past 3 years?*YesNoDo you have unconrolled chronic asthma or any clinically significan respiratory disorders that may cause difficulty taking inhaled drugs?*YesNoAre you generally in good health?*YesNoDo you take daily high dose antiinflammatory drugs such as Advil, Motrin, Aleve, or aspirin for athritis or for other reasons?*YesNoAre you currently in any other clinical trial?*YesNo Thank you for your interest! Based on the answers you provided, you do not prequalify for the Cognite Alzheimer’s Clinical Trial at this time. Your information will be destroyed and will not be saved. Thank you.Please continue filling out the pre-qualification questionnaire in order to qualify for this trial Thank you! Please choose a location below before submitting information. 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* This iframe contains the logic required to handle Ajax powered Gravity Forms. Zip/Postal Code 100 mi200 mi500 mi