SPRING Trial Pre-Screening | Spring Clinical Trial

SPRING Clinical Trial

Pre-Screening Questionnaire

Thank you for your interest in participating in the SPRING Clinical Trial for patients with P. Gingivalis positive Alzheimer’s Disease. To determine your preliminary eligibility for participating in the trial, please answer a few questions:

1. Are you completing this for yourself or someone else?

Myself

A family member or someone I care for

2. What is the potential participant's age?

< 55 years old

55 – 80 years old

80+ years old

3. Has a healthcare professional diagnosed you/them with Alzheimer’s disease?

Yes

No

Not sure

Another type of memory or cognitive condition

4. Which description best reflects your/their current level of memory impairment and independence?

Has memory problems but remains mostly independent

Needs some help with daily activities

Needs substantial help with most daily activities

Requires full-time care or is unable to participate in conversations

Not sure

5. Is there a family member or caregiver who knows you/them well and can attend study visits?

Yes

No

Not sure

6. How far are you/they willing and able to travel to a participating study site?

Up to 20 miles

Up to 50 miles

Up to 100 miles

Other

7. What ZIP code do you/they live in?

8. Are you/they currently participating in another clinical trial or receiving an investigational treatment?

Yes

No

Not sure

9. Are you/they willing to be contacted by a participating study site?

Yes

No

Authorization:

By submitting this form, you acknowledge and agree that the SPRING Study team and/or a participating study site may contact you regarding possible participation in the study. Please note that completion of this questionnaire does not guarantee eligibility or qualification for enrollment in the study.