BOOST Eligibility Questionnaire

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This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

Zb5FkRGyIoZJb7iYfUAWX6F8wEdafK5g9sTKCZYay

We are glad to hear that you are interested in participating in our research study! The purpose of this research study is to examine the relationship between physical activity, fitness, and brain and cognitive health across the lifespan. The long-term goal of this research is to gain knowledge that will help future doctors make recommendations for healthy life choices for adults.

If you are a good fit for this study, we will contact you to talk about your participation.

Thank you for your interest!

First Name

* must provide value

Last name

* must provide value

Date of birth

* must provide value

Email address

* must provide value

Phone number

* must provide value

Preferred method of contact

* must provide value

Phone

Either

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Sex

* must provide value

Male

Female

Other

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Race

* must provide value

Black/African American

Caucasian

Asian

Native Hawaiian/other Pacific Islander

American Indian or Alaska Native

Other/more than one race

Prefer not to answer

Please Describe:

* must provide value

How would you describe yourself?

* must provide value

Hispanic or Latino

Not Hispanic or Latino

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Right-handed or Left-handed?

* must provide value

Are you currently working full-time (an average of 35 hours per week)?

* must provide value

Yes

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Are you fluent in the English language?

* must provide value

Yes

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Do you have vision or corrected visual acuity of at least 20/40?

* must provide value

Yes

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Do you have normal hearing?

* must provide value

Yes

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Are you colorblind?

* must provide value

Yes

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Have you ever experienced or been diagnosed with any of the following?

-Alzheimer's disease or related dementias (e.g.,
Vascular, Lewy Body, Multiple Etiologies)
-Parkinson's disease or related dementias (e.g.,
Progressive supranuclear palsy (PSP), Multiple System
Atrophy (MSA))
-Frontotemporal dementia
-Schizophrenia
-Bipolar disorder
-Multiple Sclerosis
-Brain Surgery
-Stroke

* must provide value

Yes

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Are you currently being treated for a neurological or psychiatric condition (including ADD or ADHD, epilepsy, meningitis, Parkinson's disease, or major depression and/or generalized anxiety) that is difficult to manage with medications or you do not manage with medications?

* must provide value

Yes

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Have you ever experienced a brain injury, including major concussion (loss of consciousness)?

* must provide value

Yes

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Have you ever experienced a Transient Ischemic Attack (TIA) or brain aneurysm?

* must provide value

Yes

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Do you have arthritis, osteoporosis, or back problems that cause unmanageable pain or recent fracture?

* must provide value

Yes

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Have you had cancer in the last six months that required cancer treatment including chemotherapy, radiotherapy, or immunotherapy?

* must provide value

Yes

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Do you require caregiver assistance in dressing/personal hygiene?

* must provide value

Yes

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How did you hear about the study?

* must provide value

If not one of the above options, how did you hear about us?

* must provide value

May we contact you for future studies?

* must provide value

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