Registration and Screening Form 
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Please be aware that you will be provided with a group summary report of the findings when the study is completed. Individual findings will not be provided. 
Please take a minute to answer the questions below. Thank you!
Age (must be 60-80) *
Gender *
Are you able to read and write in English? *
Which hand do you use when writing? *
Which hand do you use when throwing a ball? *
Medical
Do you have normal (or corrected to normal) vision and hearing? *
Do you wear contact lenses? *
If you answered yes to the previous question, do you have glasses that you can wear the day of the session?
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Have you ever had a stroke? *
Do you have a pacemaker or other electrical device/implant? *
Do you have any structural abnormalities to the brain, such as a tumor or aneurysm? *
Have you ever had a traumatic brain injury, or serious head injury? *
Do you have a neurological disorder, such as epilepsy, MS or Parkinson's disease? *
Are you taking medication for the treatment of a mental health disorder? *
As a part of the study, we will record your brain activity with EEG. EEG records activity from your brain using sensors that sit on the scalp.
EEG is very sensitive to movement. The recording will require that you be able to sit in a still and relaxed position for 30 minutes without moving around. Is there anything that might limit your ability to do so? *
If you answered yes to the question above, please describe what will limit your ability to sit still for the recording. 
The EEG sensors sit on top of the head. To effectively record brain activity, the sensors must have direct contact with the scalp. As a result, we cannot record brain activity from anyone wearing a wig or toupee, or with hair extensions or braids that limit the placement of electrodes. Will this affect you in any way? *
If you answered yes to the question above, please clarify. 
The EEG sensors are small sponges and are sensitive to hair dye or coloring. We ask that you have not had your hair colored in the week before your session and that you have washed your hair twice since you have had it colored. Will this affect you in any way? *
Contact Information
Name *
Email address *
Phone number *
Preferred session days/times  *
How would like us to contact you for scheduling? *
Thank you for your interest in our study! A member of our team will contact you in 1-2 business days regarding scheduling.  Please click 'Submit' below before closing the page.
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