BCFS00529-HSL-Manor-MCI [Screening Form] -

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Please complete the screening form below about the individual with memory concerns.

Screening Form

Please complete the screening form below

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First Name

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Last Name

Phone Number

Email Address

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Gender

Male

Female

Hidden

Date of Birth

Date of Birth (mm/dd/yyyy)

What city do you live in?

What state do you live in?

What category 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

Do you have problems or concerns about your memory?

Yes

No

Have you spoken with a doctor regarding your memory or cognitive difficulties?

Yes

No

Please explain

Are you willing to travel to Boston for study visits?

Yes

No

Can you stand/walk independently, without the help of another person, for at least a minute? (Use of canes/walkers are acceptable)

Yes

No

Do you have a designated person who can serve as a study administrator (spouse, adult child, friend, family member, neighbor, etc)?

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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Tagged BCFS00529