Rush Memory Clinic Interest Form

Language : English | Spanish

Rush Memory Clinic Data Repository Interest Form

Name:

Title *First Name Middle Initial *Last Name

Address:

Street Address Apt #

City State Zip

*Phone Number

Gender Date of Birth

Caregiver Information: Optional

I am a caregiver

I have a caregiver

Type of Residence:

Home (single family dwelling) Retirement facility Nursing home

Apartment / condominium Assisted living / sheltered care Other

With what racial/ethnic group do you most closely identify yourself:

Are you of Spanish/Hispanic origin?

Yes No

In what language(s) are you fluent (reading, writing, speaking)?Check all that apply

English Spanish Other Please Specify:

Years of Education

How did you hear about us?

Flyer Presentation

Presentation Relative/Friend

Other Please Specify:

What type of research study would you like to be contacted about

Clinical trial involving investigation drugs Brain imaging studies Studies that don't involve taking medication

Contact Person:

Name Relationship Phone number

Please select an item below to indicate you level of interest in participating in the Memory Clinic Data Repository: (required)

I am very interested in becoming a research volunteer. I am somewhat interested in becoming a research volunteer. I have little or no interest in becoming a research volunteer.