The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

zshskvosMxxJqQLavUMrRb5VI792zuWMPHXpBMMzZby3XDjMx8Q2ve5qt2PvMRcazIPU2rwCbPcYZwiA3w

Registration - UBCH-CARD Registry

Thank you for your interest in participating in our Registry for the UBC Hospital Clinic for Alzheimer Disease and Related Disorders. This registry is for clinic patients and members of the public who are interested in participating in dementia related research at our clinic.

Please note that not all questions below pertain to all studies conducted at the clinic. This questionnaire is meant to include basic criteria for many different types of studies we conduct. We encourage you to fill out the form below as completely as possible in order for us to determine if there are any current studies that you may be an eligible candidate for; however, there are certain questions you can skip if you don't feel they apply to your situation or level of interest, or if you prefer not to answer them.

If, upon review, it looks like you may meet the initial criteria for a research study, you will be contacted by a study coordinator from our clinic for follow-up.

If you do not meet initial criteria for any current research study, we will retain your information and re-visit submissions periodically to review whether you meet criteria for any new studies that open in the future.

Information you provide will only be accessible to research staff on the UBCH-CARD Registry study, led by Dr. Robin Hsiung.

If you experience any technical difficulties, please contact: card.clinic@ubc.ca

Today's date

* must provide value

Y-M-D

First name

* must provide value

Last name

* must provide value

What pronouns do you use?

* must provide value

She/Her

He/Him

They/Them

Other

Prefer not to answer

reset

Email address

* must provide value

Phone number (optional)

What are the first 3 characters of your postal code?

* must provide value

What year were you born? (format YYYY)

* must provide value

What month were you born?

* must provide value

Please indicate your highest level of education.

* must provide value

Fewer than 12 years of formal education

High school

Undergraduate degree (bachelor's, associate)

Graduate degree (master's, doctorate, professional degrees)

reset

Do you feel comfortable communicating in English?

* must provide value

Yes

reset

Please indicate the language you are most comfortable:

Do you have any visual or hearing difficulties/impairments that may affect your ability to participate in a study?

* must provide value

Yes

Prefer not to answer

reset

Do you have any concerns about your memory?

* must provide value

Yes

Prefer not to answer

reset

Have you been diagnosed with cognitive impairment or dementia?

* must provide value

Yes

Not sure

Prefer not to answer

reset

Have you been diagnosed with any of the following?

* must provide value

Mild Cognitive Impairment (MCI)

Alzheimer Disease (AD)

Vascular Dementia

Frontotemporal Dementia (FTD)

Dementia with Lewy Bodies

Mixed Dementia

Other

Not sure

Prefer not to answer

reset

Other (please describe)

* must provide value

What was the approximate date of your diagnosis?
This is to help determine what studies you may be eligible for.

* must provide value

Expand

Do you have a first degree family history of dementia or a neurodegenerative condition?
(a first degree relative includes parents, siblings, or children).

* must provide value

Yes

Not sure

Prefer not to answer

reset

If you feel comfortable providing further information about any family history of dementia or neurodegenerative disease, please add more details here, otherwise feel free to leave it blank.

Expand

Please list any medical conditions you currently have.
(If you prefer not to answer this question, please leave it blank)

Expand

Are you willing and able to have an MRI scan?

Some reasons that you might not be able to have an MRI are:
-pacemaker
-aneurysm clips/wires
-cochlear implant
-severe claustrophobia

* must provide value

Yes

Not sure

Prefer not to answer

reset

What medications are you currently taking?
(If you prefer not to answer this question, please leave it blank)

Expand

Do you have any allergies?

* must provide value

Yes

Not sure

Prefer not to answer

reset

Please list any allergies you have.

Expand

Are you a patient of the UBC Hospital Clinic for Alzheimer Disease and Related Disorders?

* must provide value

Yes

Prefer not to answer

reset

Did a doctor or staff member at the UBC Hospital Clinic for Alzheimer Disease and Related Disorders mention a particular study that you may be eligible for?

* must provide value

Yes

reset

Please let us know the name of the study mentioned by your doctor/clinic staff. The name of the study should be noted on the card you received from your doctor/clinic staff about the registry.

Who were you referred by?

Are you interested in a particular study? If so, what is the name of the study?

What type of stud(ies) are you interested in? (please select all that apply)

* must provide value

No preference

Interventional studies - drug therapies

Interventional studies - other (these may include lifestyle interventions such as diet, exercise, education, etc.)

Observational studies - no intervention

Are you willing to receive emails periodically about UBC studies related to dementia which are being carried out by investigators outside of the UBC Hospital Clinic for Alzheimer Disease and Related Disorders?

* must provide value

Yes

reset

How did you find out about this registry?

* must provide value

I learned about it through the UBC Hospital Clinic for Alzheimer Disease and Related Disorders

I learned about it through word of mouth

I learned about it through an internet search

I learned about it another way

reset

Other - How did you learn about this registry?

Expand

Please add any comments or notes you would like us to be aware of.

Expand

I agree to the submission of my information provided above to Dr. Robin Hsiung and his UBC research staff, and I agree to be contacted about current or future studies related to dementia that I may qualify for.

*You will receive an email confirming your registration and information on how to opt out in the future after submitting this form.

* must provide value

I agree

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.