Research Volunteer Portal - Australian Dementia Network

Please take a moment to look at the information and questions and then if you wish to proceed:

enter your contact details (Part 1)
answer the 14 questions below (Part 2)
choose the type of trials you would like to participate in (Part 3)
click the Sign-Up button

If you would later like to remove yourself from our contact list or alter the information just send an email with your request to adnet-trials@unimelb.edu.au.

General Information About Research Trials
Trials vary in type. Some test drugs that may prevent or treat dementia. These are called clinical drug trials. Others test lifestyle changes such as exercise programs or the value of intensive treatment of risk factors such as high blood pressure. These are called lifestyle intervention trials. Others follow volunteers for many years to learn more about the causes of dementia. These are sometimes called observational studies. They may ask you to fill in an “on-line” questionnaire and memory test on your home computer. Or they may ask you to have a face-to-face meeting with researchers. These take up more time, and may ask you to have brain scans, to give a blood sample, and to have detailed memory and thinking testing. Some even ask you to have a lumbar puncture (spinal tap) to analyse the fluid that surrounds the brain.

ADNeT Trials
If you match our current research requirements, we will contact you to confirm if you are interested in a much more detailed assessment that includes brain scans, blood tests and memory testing. Depending on the test results, you may be recommended to take part in a trial or be included in the ADNeT longitudinal observational study assessing the causes and development of dementia or be asked to consider a clinical drug trial or a lifestyle trial.

You can also download a free App to your smart phone or computer called ClinTrialRefer that lists all dementia treatment trials currently running in Australia and contains the contact details for the trial sites. The dementia trials section of this App is sponsored and managed by the Australian Dementia Network, a Federally funded initiative to fast track trials and improve the quality of diagnosis and care.

Part 1. Contact Details

Given Name*

Family Name*

Date of Birth*

Email*

Gender*

Phone Number*

Contact Time

Post Code*

Do you agree for your information to be included in our database for future contact?*

Yes
No

Part 2. ADNET Questionnaire

Please complete all questions

1. Are you concerned about your memory?*

Yes
No

2. Are others concerned about your memory?*

Yes
No

3. Is your memory worse than it was 3 years ago?*

Yes
No

4. Has a doctor told you that you have Mild Cognitive Impairment?*

Yes
No

5. Has a doctor told you that you may have dementia?*

Yes
No

5. a) If yes, do you have*

5. b) If yes, is your dementia*

6. Has your doctor performed a Mini Mental State Examination (MMSE) or MOCA test?*

Yes
No

6. a) What is your MOCA Score?

Leave blank if unknown or not applicable

Please enter a number from 0 to 30.

6. b)What is your MMSE Score?

Leave blank if unknown or not applicable

Please enter a number from 0 to 30.

7. Were either of your parents, or any of your brothers or sisters diagnosed with dementia?*

Yes
No

8. Are you comfortable reading and speaking English?*

Yes
No

9. Did you finish primary school?*

Yes
No

10. Are you in good physical health?*

Yes
No

11. Do you consent to providing a saliva sample to carry out genetic testing?*

Yes
No

11. a) If you answered yes, we may send you a saliva test kit in the mail for you to complete and mail back to us. What is your mailing address?*

Street Address Address Line 2 Suburb State Post Code

12. Do you consent to us contacting you about research trials?*

Yes
No

13. Have you had any of the following:

cancer not in remission for the last 3 years except localised prostate cancer or basal or squamous cell skin cancer?*

Yes
No

Schizophrenia?*

Yes
No

severe depression in the last 5 years?*

Yes
No

alcohol or drug abuse in the last 2 years?*

Yes
No

stroke, multiple sclerosis or serious head injury requiring a week or more in hospital*

Yes
No

HIV?*

Yes
No

14. Do you have any of the following that make it unsafe to have an MRI scan:

cardiac pacemaker/defibrillator?*

Yes
No

metal fragments in the eye?*

Yes
No

cochlear implant?*

Yes
No

neural stimulator?*

Yes
No

Part 3. Trials

Please indicate what types of trial or study you are interested in by checking the list below.

Clinical drug trial*

Yes
No

Lifestyle intervention (e.g. exercise, brain training, depression, sleep)*

Yes
No

Observational study – on-line*

Yes
No

Observational study – direct contact (attending a centre for face to face testing, blood tests and brain scans)*

Yes
No

Email

This field is for validation purposes and should be left unchanged.