Alzheimer’s Disease Clinical Trial Screening Sheet
Participant Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone
Email
Address
Medical History
Diagnosis of Alzheimer’s disease?
Yes
No
Suspected
Date of Diagnosis
Stage of Alzheimer’s
Mild
Moderate
Severe
Other Neurological Conditions
Eligibility Criteria
Meets Age Criteria?
Yes
No
Mini-Mental State Examination (MMSE) Score
Other Inclusion/Exclusion Comments
Additional Information
Current Medications
Allergies
Caregiver Name
Caregiver Phone
Assessor Details
Screening Date
Assessor Name
Notes