Evanthea - Dementia Reversal Trial

Pre-Screening Survey

Thank you for your interest in the Evanthea Dementia Reversal Trial, a randomized clinical trial using precision medicine that targets the underlying causes of cognitive decline (including diet and lifestyle changes) and the positive impacts on reversing early dementia and mild cognitive impairment. We ask you to take a few minutes to answer the below pre-screening questions to determine if you are a qualified candidate.

By entering in your contact information, you consent to one of our staff members contacting you to discuss the study in more detail if you meet our early criteria requirements.

www.DementiaReversalTrial.com

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* 1. Enter Information

Contact's First & Last Name

Contact's Email

Contact's Phone Number

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* 2. First and Last Name of Candidate (if different than above)

Please answer all below questions from the perspective of the study candidate.

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* 3. This is a randomized clinical trial, which means that if you are selected as a final candidate, it is possible you could be selected for the delayed group. This means you would receive high quality, usual and customary treatment for the 9 months of the trial and then you will have the option to receive up to six months of precision medicine treatment and testing at no cost following the completion of the trial. Do you agree to being part of a randomized trial?

Yes

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* 4. Select your age range.

35 - 44

45 - 54

55 - 64

65 - 76

77+

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* 5. Select any cognitive symptoms you have experienced in the last 6 months.

More forgetful than usual

Forgetting words or substituting words that don’t fit into a conversation

Forgetting things often or struggling to retain new information

Frequently misplacing items

Needs a list for everything

Difficulty recognizing or remembering familiar people and places

Difficulty doing arithmetic, paying bills or managing finances

Lost interest in friends, family and favorite activity/hobby

Difficulty performing familiar tasks

Difficulty organizing information, appointments or schedule

Becoming lost while walking or driving, or new challenges with driving or navigating

Unable to dress or feed yourself

Changes in mood

Major change in personality

None of the above

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* 6. How long have you been experiencing any of the above symptoms:

6 months – 1 year

1 - 2 years

3 - 4 years

5+ years

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* 7. Select which best represents your cognitive symptom decline in the last 6 months:

Rapidly progressing

Moderately progressing

Has not progressed

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* 8. Have you made any of the below changes in the last 6 months:

Incorporated a new diet

Increased amount of exercise

Incorporated stress reduction techniques

Started new supplements

Started any new medications

None of the above

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* 9. If you selected any of the above, please elaborate on what diet/supplements/medications/stress techniques/exercise you have incorporated in the last 6 months?

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* 10. Select the option that best represents you:

I live alone and do not have continuous support

I live with a spouse/partner/family member/roommate

I have family or support person nearby

Other (please specify)

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* 11. Select the option that best represents you:

I have regular reliable transportation

I sometimes have reliable transportation

I do not have reliable transportation

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* 12. Do you live within one hour to any of the below trial sites? Select the closest trial site to you below.

Folsom, CA

San Rafael, CA

Hollywood, FL

Rocky River, OH

Nashville, TN

None of the above

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* 13. If yes, select how far you live from the closest trial site to you.

1 – 20 miles

21 – 40 miles

41 – 50 miles

51 – 60 miles

61+ miles

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* 14. Please enter your zip code below.

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* 15. Please read the following statements carefully. Select Yes or No for your response.

	Yes	No
For the next 9-12 months I will be in the area and not traveling more than 2 weeks at a time.	For the next 9-12 months I will be in the area and not traveling more than 2 weeks at a time. Yes	For the next 9-12 months I will be in the area and not traveling more than 2 weeks at a time. No
All existing medical conditions and any current medication dosages are stable (if not on any medications select YES).	All existing medical conditions and any current medication dosages are stable (if not on any medications select YES). Yes	All existing medical conditions and any current medication dosages are stable (if not on any medications select YES). No
I have access to a computer and regular, reliable internet connection.	I have access to a computer and regular, reliable internet connection. Yes	I have access to a computer and regular, reliable internet connection. No
I have the ability to use a computer and internet, or have readily available assistance to facilitate the use of a computer and internet.	I have the ability to use a computer and internet, or have readily available assistance to facilitate the use of a computer and internet. Yes	I have the ability to use a computer and internet, or have readily available assistance to facilitate the use of a computer and internet. No
I am willing to make diet, lifestyle, supplement, and medication changes for the study.	I am willing to make diet, lifestyle, supplement, and medication changes for the study. Yes	I am willing to make diet, lifestyle, supplement, and medication changes for the study. No
I am able to exercise.	I am able to exercise. Yes	I am able to exercise. No
I am willing to have an MRI brain scan and coronary artery calcium scan.	I am willing to have an MRI brain scan and coronary artery calcium scan. Yes	I am willing to have an MRI brain scan and coronary artery calcium scan. No
I am willing to allow a home evaluation by an Evanthea Project team member for any suspected toxins or mold than can contribute to cognitive decline.	I am willing to allow a home evaluation by an Evanthea Project team member for any suspected toxins or mold than can contribute to cognitive decline. Yes	I am willing to allow a home evaluation by an Evanthea Project team member for any suspected toxins or mold than can contribute to cognitive decline. No
I am willing to remediate and/or move away from identified sources of toxicity such as environmental (mold or other toxins) or dental toxicities/infections considered to be contributing to cognitive decline. These will be identified and discussed with me based on study screening results. The cost of the remediation and dental procedures are not covered by the study.	I am willing to remediate and/or move away from identified sources of toxicity such as environmental (mold or other toxins) or dental toxicities/infections considered to be contributing to cognitive decline. These will be identified and discussed with me based on study screening results. The cost of the remediation and dental procedures are not covered by the study. Yes	I am willing to remediate and/or move away from identified sources of toxicity such as environmental (mold or other toxins) or dental toxicities/infections considered to be contributing to cognitive decline. These will be identified and discussed with me based on study screening results. The cost of the remediation and dental procedures are not covered by the study. No
I am willing to comply with general study procedures, including, but not limited to regular blood and cognitive testing, MRI, cone bean dental CT scans, hearing and vision exams, DEXA bone scans, and COVID testing as indicated.	I am willing to comply with general study procedures, including, but not limited to regular blood and cognitive testing, MRI, cone bean dental CT scans, hearing and vision exams, DEXA bone scans, and COVID testing as indicated. Yes	I am willing to comply with general study procedures, including, but not limited to regular blood and cognitive testing, MRI, cone bean dental CT scans, hearing and vision exams, DEXA bone scans, and COVID testing as indicated. No

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* 16. Do you identify with any of the below statements? Yes or No

	Yes	No
I have the presence of an uncontrolled major medical illness (e.g. seizures, cardiovascular disease, etc.)	I have the presence of an uncontrolled major medical illness (e.g. seizures, cardiovascular disease, etc.) Yes	I have the presence of an uncontrolled major medical illness (e.g. seizures, cardiovascular disease, etc.) No
I have had previous treatment using dietary changes, comprehensive nutritional support, ReCODE (Bredesen Protocol) or a similar methodology such as functional, integrative, or systems medicine.	I have had previous treatment using dietary changes, comprehensive nutritional support, ReCODE (Bredesen Protocol) or a similar methodology such as functional, integrative, or systems medicine. Yes	I have had previous treatment using dietary changes, comprehensive nutritional support, ReCODE (Bredesen Protocol) or a similar methodology such as functional, integrative, or systems medicine. No
I have the presence of major psychiatric diagnoses that impact the performance of activities of daily living or functioning, other than those conditions related to cognitive decline.	I have the presence of major psychiatric diagnoses that impact the performance of activities of daily living or functioning, other than those conditions related to cognitive decline. Yes	I have the presence of major psychiatric diagnoses that impact the performance of activities of daily living or functioning, other than those conditions related to cognitive decline. No
I have a prior traumatic brain injury of sufficient severity that impacts my regular functioning.	I have a prior traumatic brain injury of sufficient severity that impacts my regular functioning. Yes	I have a prior traumatic brain injury of sufficient severity that impacts my regular functioning. No
I have had a diagnosis of cancer in the past 5 years (other than basal cell or squamous cell skin cancer).	I have had a diagnosis of cancer in the past 5 years (other than basal cell or squamous cell skin cancer). Yes	I have had a diagnosis of cancer in the past 5 years (other than basal cell or squamous cell skin cancer). No
I have the presence of existing diagnosis of non-Alzheimer's neurodegenerative disorder (e.g. Lewy Body Disease, Frontotemporal Disease, Chronic Traumatic Encephalopathy, Korsakoff's Syndrome, etc.)	I have the presence of existing diagnosis of non-Alzheimer's neurodegenerative disorder (e.g. Lewy Body Disease, Frontotemporal Disease, Chronic Traumatic Encephalopathy, Korsakoff's Syndrome, etc.) Yes	I have the presence of existing diagnosis of non-Alzheimer's neurodegenerative disorder (e.g. Lewy Body Disease, Frontotemporal Disease, Chronic Traumatic Encephalopathy, Korsakoff's Syndrome, etc.) No
I am a current user of tobacco products, cannabis, or other illicit drugs.	I am a current user of tobacco products, cannabis, or other illicit drugs. Yes	I am a current user of tobacco products, cannabis, or other illicit drugs. No

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* 17. How did you hear about this clinical trial?

Website

Facebook

Instagram

Flyer

Newspaper

Friend

Doctor's office

Other (please specify)

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* 18. If found not to be an eligible candidate for this clinical trial, would you like to be contacted by the nearest trial site to you about memory treatment with precision medicine options outside of the trial?

Yes