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Questionnaire for Potential Participants in the AD Pilot Treatment Program using existing FDA Approved Medications 

If after filling out the questionnaire, you are selected by our Program Team to participate in the ZN Pilot Treatment Program, you will be contacted by one of our staff members by email and or telephone. Note participants that show signs of being at a higher risk for developing MCI and or early-stage Alzheimer's one of our staff members by email and or telephone. Note participants that show signs of being at a higher risk for developing MCI and or early-stage Alzheimer's after taking the LabCorp or Quest Diagnostics blood test will be eligible to participate in the Pilot Treatment Program. Participants with primary care physicians and or neurologists currently involved in the individual's prognosis will be given a priority at this time due to the involvement of your local physician(s). 

Contact Information

Potential Patient's Name
Person filling out the form if different than the potential patient 
Relationship to Patient
City and State of Potential Patient *
Email Address of Contact Person *
Telephone Number *
Primary Doctor's Name *
Primary Doctor's Phone Number *
Primary Doctor's Email Address *
Neurologist's Name if applicable
Neurologist's Phone Number if applicable
Neurologist's Email Address if applicable

Background Questions
Have you been diagnosed by a physican as having cognitive issues such as Mild Cognitive Impairment or early stage Alzheimer's ? 


Did or does anyone in your family (siblings, parents, grand parents, aunts, or uncles) have any type of cognitive disorder such as Alzheimer's, Dementia, or Mild Cognitive Impairment?

Have you had a concussion, head injury with loss of consciousness, disorientation, or consistant confusion, or recent memory losses ?

On average do you sleep for at least six-eight hours per night?

Do you have high blood pressure?

Do you have heart problems?

Have you ever had a stroke?

Do you have diabetes?

Do you have high cholesterol?

Do you have difficulty with language, such as finding the right words or following a conversation or forgetting the subject matter being discussed?

Have you had any recent falls or accidents?

Insurance Coverage & Potential Financial Requirements
While your insurance healthcare provider may cover all or most of the LabCorp or Quest Diagnostics blood tests and the medications, if they do not are you able to pay for the LabCorp or Quest Diagnostics blood test and the medications. The estimated cost of the blood test ranges from $399 to $599 and the monthly medications are estimated to range between $150 to $250 without healthcare coverage. Note Zachriel Neurosciences Foundation will also be seeking grants and private donations to help support the pilot program for those individuals that may not have the type of healthcare insurance that will cover these costs.   

Authorization for My Protected Health Information Form     
By signing below I confirm I have read the Zachriel Neurosciences (ZN) “ My Protected Health Information” form, and agree to its terms and conditions for use by Zachriel Neurosciences. I understand I can withdraw my authorization at any time by submitting a written request to ZN advising them I want to withdraw my authorization and will no longer participate in the ZN pilot program.    

Thanks for submitting!

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