Skip to content
Screening Form
Please complete the screening form below
First Name
Hide on Form
Last Name
Hide on Form
Phone Number
Email Address
Gender
Show on Form
Male
Female
Date of Birth
Hide on Form
What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Other
Prefer not to list
Do you have any concerns or conditions that may affect your ability to see text clearly on documents or computer screens, with or without the use of correctable lenses?
Yes
No
Are you willing and able to participate throughout the entire duration of the study, including all procedures such as brain imaging and blood draws?
Yes
No
Do you have any major clinical conditions or diseases that could significantly impact your health (excluding Type II Diabetes, hypercholesterolemia, and hypertension)?
Yes
No
Do you have any significant neurological diseases such as Parkinson's disease, multiple sclerosis, brain cysts, tumors, or aneurysms?
Yes
No
Do you have any significant psychiatric disorders such as schizophrenia, bipolar disorder, or attention-deficit hyperactivity disorder (excluding depression and anxiety)?
Yes
No
Do you have an existing diagnosis of dementia or mild cognitive impairment?
Yes
No
Within the past 2 years, have you encountered any challenges related to alcohol or substance use, including difficulties in controlling your alcohol or substance use?
Yes
No
Do you have any conditions or implanted devices that would prevent you from undergoing an MRI, such as pacemakers, aneurysm clips, artificial heart valves, ear implants, or any metal fragments or foreign objects in your eyes, skin, or body?
Yes
No
Do you have any conditions or situations that would prevent you from undergoing a PET scan, such as having had significant prior radiation exposure?
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.
Captcha
Hide on Form
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00586
