Alzheimer's Questionnaire-Rd 2 (Prescription Med)

People living with Alzheimer's Disease: Project Submission Form

Hello. Thank you for taking the time to respond!
Please fill out the questionnaire below. It should only take a few minutes. Once submitted, you may be contacted by a GENUINE Team member for a follow-up video interview to be viewed by our team and clients.

If you experience difficulty taking this survey or have questions about the project, please contact GENUINE at realpeople@genuinerp.com or (212) 966-3211 x 620.

If you have any questions about the information you provide to us, you can read GENUINE's Privacy Policy.

Okay, let's get started!
Who is filling out this form?*

Adult diagnosed with mild cognitive impairment (MCI) due to Alzheimer's diseaseAdult diagnosed with mild Alzheimer's dementia (or mild dementia due to Alzheimer's disease)Care partner for/on behalf of the person diagnosed with mild cognitive impairment (MCI) due to Alzheimer's diseaseCare partner for/on behalf of the person diagnosed with mild Alzheimer's dementia (or mild dementia due to Alzheimer's disease)
Good to know, thank you!

If you are a care partner, please keep in mind that this survey has been written for the person diagnosed with Alzheimer's disease, so "you" will refer to that person.
Full Name (Person diagnosed with Alzheimer's disease)*

First NameLast Name
Full Name (Care Partner, if applicable)

First NameLast Name
Person diagnosed with Alzheimer's disease - Phone Number*

Area CodePhone Number
Person diagnosed with Alzheimer's disease - Email*
Care Partner - Phone Number*

Area CodePhone Number
Care Partner - Email*
example@example.com
Home State*
City*

During this survey, we will be asking you about your medical history/health as it relates to your diagnosis of Alzheimer's disease. Please select "I permit" below if you or your care partner mentioned above are willing to share information about your health as it relates to your diagnosis of disease for the purposes of recruiting for this project.

MEDICAL CONDITIONS

Subject to your agreement to the waiver below, please share information regarding any medical conditions that you may have and are comfortable discussing publicly for potential projects. You acknowledge and understand that your personal health information may be protected from disclosure by the Health Insurance Portability and Accountability Act ("HIPAA") and other privacy laws. By selecting, "I permit" below, you consent to GENUINE electronically storing the personal health information that you disclose and reviewing it for purposes of contacting you about future projects for which you may be suited.
By selecting one of the options below, you acknowledge that you have read and understand the above statement.*

I permit GENUINE to store and access my personal health information for purposes of contacting me for projects.I decline to provide my personal health information.

Now we'd like to hear more about your diagnosis and experiences living with Alzheimer's disease.
Which of the following have you been diagnosed with? (please select all that apply)*

Mild Cognitive Impairment (MCI) due to Alzheimer's diseaseMild Alzheimer's dementia (or mild dementia due to Alzheimer's disease)None of the aboveI'm not sureOther

Have you been diagnosed with this condition(s) by a health care professional (HCP)?*

YesNoI don't knowOther
When were you diagnosed? (Please specify month/year)*
If requested at a later time, would you be able to provide a Physician's Note confirming your diagnosis?*

YesNoI don't knowOther
What medications are you currently taking for Alzheimer's disease?*

Please upload a recent photo of yourself, if possible.

Browse Files
NO sunglasses, hats or edited/photoshopped photos. NO filters. We must be able to see your [real] face. Cancelof

Thank you so much for taking the time to answer all of our questions.

Please click on the "Submit" button to complete this questionnaire.
Should be Empty:

	Yes	No	I'm not sure
I have been paid to work as an actor or model.
I have been featured in a project for TV, Film, and/or Digital Media.
I currently have or am seeking representation/ an agent/ a manager.
I have booked a project with GENUINE in the past.
I am a member of SAG-AFTRA.
I am a member of Actor's Equity Association.
I am pursuing professional acting/ modeling opportunities.

People living with Alzheimer's Disease: Project Submission Form