Study questionnaire - Douglas Mental Health University Institute

1. Are you 60 years of age or older?

Yes
No

2. Did either of your parents or any of your brothers or sisters have Alzheimer's Disease or memory problems that got worse over time?

Yes
No

If yes, which of these blood relatives have -or had- this kind of memory problem or senility (check all that apply)

Mother
Father
Sister(s)	number
Brother(s)	number

3. Participants in the study will be asked to come to our offices for visits five times in the first year and twice more in the second year. The study requires that participants have someone who knows them well and who can accompany them to study appointments. Do you have someone who can come with you for these kinds of visits?

Yes
No

4. The study requires that participants must be able to read and write English, because we will ask them to perform some memory tests in English. Do you have any problem writing or reading English?

Yes
No

If you answered YES to the 4 questions above, please continue
If you aren't sure of your answers to the following 7 questions, answer "No"

5. Because the purpose of this study is to learn if we can prevent memory problems, we have to limit enrolment to people who have never been diagnosed with memory problems or Alzheimer's Disease. Has a doctor or nurse ever told you that you had Alzheimer's disease or memory problems?

Yes
No

6. Have you ever had a bleeding ulcer in your stomach or your intestine that resulted in a hospitalization or required a blood transfusion?

Yes
No

7. Are you allergic to aspirin, ibuprofen (Advil) or any other pain medication?

Yes
No

8. Are you currently taking blood thinners like Coumadin, Heparin, Plavix, Aggrenox or Ticlid?

Yes
No

9. Are you taking any anti-inflammatory medicines like ibuprofen, Aleve, Advil, Naprosyn, or Voltaren, four or more times per week?

Yes
No

10. Are you taking Zantac, Tagamet, Pepcid or Axid four or more times per week?

Yes
No

11. Are you currently taking prednisone or any other steroid (including steroid inhalers like Flovent, Pulmicort, Beclovent, Becloforte or Symbicort) four or more times per week?

Yes
No

If you answered NO to questions 5 to 11, you may be eligible to participate.
We invite you to contact our medical staff to know more about the program at : 1-855-888-4485

You can also fill this information card and the medical staff will contact you when it is more convenient for you.

Best time of the day to reach you

am
pm
anytime

Thank you ,we will contact you shortly. The PREVENT-AD team

Name
Surname
Age
Telephone