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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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Last Name
Phone Number
Email Address
What is the best time to contact you?
Early Morning (8AM-10AM)
Late Morning (10AM-12PM)
Early Afternoon (12PM-3PM)
Late Afternoon (3PM-5PM)
Evening (5pm-7pm)
What is your preferred method of contact?
Phone call
Email
Text
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Gender
Male
Female
Other
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Date of Birth
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What city do you live in?
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What state do you live in?
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
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Kansas
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Louisiana
Maine
Maryland
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Michigan
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New Hampshire
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New York
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
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Select all of the following that best describes you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Which of the following neurological conditions have you been diagnosed with?
Alzheimer's disease
Dementia
Mild Cognitive Impairment (MCI)
Parkinson's disease
Epilepsy
Stroke
Multiple sclerosis
Amyotrophic lateral sclerosis (ALS)
Traumatic brain injury (TBI)
Other
None of the above
What medications are you currently taking?
Please choose the vision correction that best applies to you:
I have natural vision without the need for visual aids
I wear contact lenses or glasses to correct my vision
I have poor vision and do not use contact lenses or glasses to correct my vision
Which of the following statements apply to your pregnancy status or experience?
Not pregnant/Not applicable
Currently pregnant
Planning to become pregnant in the near future
Recently gave birth
Currently breastfeeding
Do you have any limitations that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body (implants, pacemakers, etc.) or experiencing claustrophobia?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
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BCFS001257
