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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
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Gender
Male
Female
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Date of Birth
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
Are you between the ages of 55 and 85?
Yes
No
Have you ever had a history of a brain tumor, MRI evidence indicating brain damage or disease, or experienced significant brain trauma?
Yes
No
Have you been diagnosed with any of the following:
Cognitive impairment
Alcoholism or drug abuse within the last 5 years
Insulin-dependent diabetes
History of schizophrenia, bipolar disorder, PTSD, or a major depressive episode in the last 2 years
Sleeping Disorder
None of the above
Do you have any significant heart, lung, hormone, or blood-related conditions?
Yes
No
Do you have physical impairments severe enough to affect the validity of psychological testing?
Yes
No
Do you have any limitations or conditions that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body (e.g., pacemaker, surgical clips, artificial joints), having tattoos larger than 1cm in diameter, or experiencing claustrophobia?
Yes
No
Are you taking strong painkillers or regularly using medications that affect your body's natural functions (narcotic analgesics, medications with anticholinergic activity, etc) ?
Yes
No
Are you using anti-Parkinsonian medications?
Yes
No
Has any of your immediate family members (parents, siblings) been diagnosed with dementia before the age of 60?
Yes
No
Have you taken any radioactive medicines in the 7 days leading up to this study?
Yes
No
Have you participated in other research studies involving ionizing radiation in the past year?
Yes
No
Have you ever used intravenous (IV) drugs in a way that might make it hard to inject the PET tracer?
Yes
No
Have you fainted from a needle prick in the past?
Yes
No
Preferred method of contact:
Email
Phone
Have you been diagnosed with a sleeping disorder (Obstructive Sleep Apnea, Insomnia, Narcolepsy, etc....)?
Yes
No
Best time to contact you:
Morning (9 am - 12 pm)
Afternoon (1 pm - 5 pm)
Other (please specify):
If you have been diagnosed with Obstructive Sleep Apnea, do you use a CPAP machine or any other form of treatment?
Yes
No
I have not been diagnosed with Obstructive Sleep Apnea
Please specify the best time to contact you:
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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BCFS00645
