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Please complete the following for us to better understand your medical need. Age between 20 - 30 Age between 31 - 40 Age Between 41- 50 Age between 51 - 60 Age between 61 - 70 Age between 71 and older My health is good My health is average My health is poor I am on chronic medication

I suspect I might have Alzheimer's disease. I have the following symptoms

I would like to be a medical trial volunteer Yes No

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If your answer to the previous question was no, please tell us how you would like for us to assist you?

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