International Patient Enrollment Form Treating Physician * First Name Last Name Office Phone Number * (###) ### #### Email * Medical License Number * Clinic Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Patient's information Please do NOT provide Patient's name in the following sections Patient's Date of birth * MM DD YYYY Sex * Male Female Race * White Black Asian Other Patient's Medical History Please do NOT provide Patient's name in the following sections Past & current medical history * If the patient has experienced seizures, strokes, or heart attacks, please provide the history, date of recent event, frequency, and treatment details * If no, please enter N/A Current medications, doses, and indications * Relevant family history * Approximate height (ft' in") and weight (lbs) * Recent blood pressure values (mmHg) * Date of Measurement for blood pressure * MM DD YYYY Please submit full EKG interpretations from within the past 6 months, including the following values: heart rate, PP interval, QT interval, PR interval, and QRS duration. We require the corrected QT, and either QTcB or QTcF is acceptable. * Just stating "Normal Sinus Rhythm" will not be accepted. Date of Completion for EKG * MM DD YYYY MRI, Amyloid PET, and/or CT Scan interpretation - please include the date completed * Recent clinical laboratory findings: CBC and Comprehensive Metabolic Profile (including kidney and liver functions) from the past 6 months - please provide values and include the date completed From any recent visits or from primary MD. Please provide values - Just stating "Normal" or "WNL" will NOT be accepted' Date of Completion for CBC Labs * MM DD YYYY Please provide CBC results with actual values, including WBC, RBC, HGB, HCT, and platelet count. If any are abnormal, please include a differential CBC with neutrophils, lymphocytes, monocytes, and other relevant parameters * If you suspects an infection, inflammation, please provide CBC with differential. Date of Completion for Metabolic Panel * MM DD YYYY Sodium * Potassium * Chloride * CO2 (carbon dioxide) * BUN (blood urea nitrogen) * Creatinine * Glucose * Albumin * Calcium * AST (aspartate aminotransferase) * ALT (alanine aminotransferase) * ALP (alkaline phosphatase) * Total bilirubin * Total protein * Magnesium (recommended) Any other values that you think would be critical (optional) TB006 is ineffective in patients with a homozygous mutation at the rs4644 LGALS3 locus. Genetic screening for the rs4644 LGALS3 SNP is necessary to determine patient response. Please conduct the screening and report the patient's rs4644 LGALS3 genotype (e.g., wild-type, heterozygous, homozygous) below. * You can leave it as "pending", and provide the results later. Dementia history Please do NOT provide Patient's name in the following sections Alzheimer's disease onset (year and age) * Brief history of dementia * Course of dementia and loss of independence * Dementia medications used * Response to dementia medications used * Is the patient currently on any anti-amyloid treatments, such as Donanemab (Kisunla) or Lecanemab (Leqembi®)? If yes, they cannot use TB006 in combination with anti-amyloid drugs. * Recent MMSE score (within the last 3 months) and additional clinical observations during the assessment, such as speech, orientation, etc. * Date of MMSE assessment * Has to be done within 3 months MM DD YYYY Thank you! Your patient enrollment form is currently under review. We will contact you within a week with an update. If we require additional information, we will reach out shortly.
