Questionnaire

Who is filling out this form? (Choose one)

I am a patient who is taking LEQEMBI.

I am a care partner for or family member of someone who is taking LEQEMBI.

I am not taking LEQEMBI yet, but I have been talking to my health care provider about starting soon.

I have been diagnosed with early Alzheimer’s disease, mild cognitive impairment (MCI) or mild dementia stage of Alzheimer’s disease.

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.

Person diagnosed with Alzheimer's disease (if applicable):

Full Name:

Phone Number:

Email:

Care Partner or Family Member (if applicable):

Full Name:

Phone Number:

Email:

In which state do you currently reside?

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

Mild Cognitive Impairment (MCI) due to Alzheimer's disease

Mild Alzheimer's dementia (or mild dementia due to Alzheimer's disease)

None of the above

I am not sure

Other

Do you have a care partner, family member, or someone in your life who assists you in your everyday routine?

Yes

No

N/A

What is your Alzheimer’s disease (AD) story? Please include relevant treatment with LEQEMBI if applicable.

Have you ever appeared in any medical, pharmaceutical or health care marketing communication/advertising/initiatives/ambassador programs? If yes, please provide details below. If no, please write N/A.

Are you or any household members currently employed by any of the following? (please select all that apply)

Pharmaceutical manufacturer or contract research organization (CRO)

Medical equipment manufacturer

Market research or advertising firm

FDA or other government agency

None of the above

(OPTIONAL) In order to track the effectiveness of our efforts and ensure we consider the needs of our project, please consider answering the following questions:

Thank you for taking the time to provide this information.

In order to submit your story, you must agree to these Terms and Conditions.

Terms and Conditions

1. Eligibility:

I confirm that I am a U.S. resident and 18 years of age or older.

2. Accuracy of Information

I confirm that the information I provide is accurate to the best of my knowledge and that I am submitting my own story or have permission to share on behalf of someone else.

3. Purpose of Submission

By submitting my story, I agree to share my personal experience with early Alzheimer’s disease, which may include my use of prescription medications, to potential outreach, education, or research engagement by Eisai.

If my story includes references to prescription medications, I confirm that the information is based on my personal experience or that of someone I am authorized to represent.

4. Consent (Patient)

Yes. By checking this box, I consent to Eisai collecting and using the information I provide about me, some of which may be considered “sensitive” or “health data", and further share it with its service providers for determining eligibility/qualification for a future opportunity. I understand that I may withdraw my consent at any time by following the instructions on our “Your Choices and Rights” page (available here: https://us.eisai.com/privacy-policy/your-choices-and-rights).

Visit Eisai’s Privacy Policy and Legal Notices for more information.

5. Use of Information

Your submission will not be published, shared, or used without:

A follow-up conversation initiated by Eisai, and
Your explicit written consent.

Eisai will not use your story for promotional or marketing purposes without your prior approval.

Your personal and health information will be kept confidential and stored securely.
Only authorized Eisai personnel will access your submission for the purpose of potential follow-up.

Your story will not be linked to your identity unless you provide written permission.
Eisai may be required to report certain information to regulatory authorities (e.g., adverse events related to medications). If so, your identity will remain confidential unless disclosure is required by law.

6. No Obligation
Submitting your story does not obligate Eisai to contact you or use your story in any way.

Send me a copy of my responses

Please click "Submit" button to complete this questionnaire.