Please Fill Out This Survey

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Your Contact Information

(All information is required unless otherwise noted.)

First Name	Last Name
Email Address

Check here if you would also be interested in receiving additional information by postal mail in the future.

Street Address - Line 1	City
Street Address - Line 2 (Optional)	State

5-Digit Zip Code (This program is open to U.S. residents only.)

Gender:

Female Male

Date of Birth:

Condition Information

Are you, or someone you care for, experiencing memory problems or other symptoms of Alzheimer's disease?

Yes, I am experiencing symptoms
Yes, someone I care for is experiencing symptoms
No, neither I nor someone I care for is experiencing symptoms

What is your relationship to this person?

Spouse
Child or Child-in-law
Relative
Friend
Healthcare professional

Are you primarily responsible for your loved one with Alzheimer's disease (e.g., taking him/her to the doctor, feeding him/her)?

Yes No

Please respond to the following questions as they pertain to this person. By completing this form, you agree that you are authorized to provide this information on his/her behalf.

Has this person been diagnosed with Alzheimer's disease by a healthcare professional or physician?Have you been diagnosed with Alzheimer's disease by a healthcare professional or physician?

Yes No

When was this person first diagnosed with Alzheimer's disease?When were you first diagnosed with Alzheimer's disease?

[If you are not sure, please approximate.]

Is this person currently taking any medication to treat the symptoms of Alzheimer's disease?Are you currently taking any medication to treat the symptoms of Alzheimer's disease?

Yes No

Is this person currently taking Namenda^® (memantine HCl)?Are you currently taking Namenda^® (memantine HCl)?

Yes No

When did this person begin treatment with Namenda^®?When did you begin treatment with Namenda^®?

[If you are not sure, please approximate.]

Is this personAre you currently taking any of these medications to treat Alzheimer's disease: Aricept^® (donepezil HCl), Razadyne^® ER (galantamine HBr), or Exelon^® (rivastigmine tartrate)? [Aricept^®, Razadyne^®, and Exelon^® are registered trademarks of their respective manufacturers.]

Yes No

When did this person begin treatment with that medication?When did you begin treatment with that medication?

[If you are not sure, please approximate.]

Your Privacy Information

The information you provide may be used by Forest Laboratories, Inc., its business partners and consultants to provide you with information about Forest Laboratories, Inc. products, or health issues, or to develop services concerning health conditions. Please read our Privacy Policy for additional details about the policies that govern our collection, use, and disclosure of the information that you may provide.

By providing my information and clicking "Submit", I agree to receive requested materials and information about Alzheimer's disease, and related Forest Laboratories, Inc., products and health issues. I permit Forest Laboratories, Inc. to use my personal information as specified in the Privacy Policy.