Participant History for Neurologically Healthy Participants

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Please fill out this form to tell us more about yourself.

Personal Contact Information

Last name *

First name *

Gender *

Today's Date

YYYY

Age *

Date of Birth *

YYYY

Address *

Phone number (primary) *

Phone number (secondary)

E-mail

Marital Status *

Married

Single

Name of Spouse

Name of Legal Representative (if different from spouse)

Phone number of Legal Representative

Address of Legal Representative

Handedness *

Right

Left

Ambidextrous

Personal and Family History

Native Language *

What is your dominant language?

Language 1

Please list any other languages you speak

Language 2

Please list any other languages you speak

Language 3

Please list any other languages you speak

Other languages

How well do you speak other languages?

Fluent

Basic

Clear selection

Ethnicity *

Hispanic or Latino

American Indian/Alaskan Native

Asian

Native Hawaiian/Pacific Islander

Black or African American

White (not Hispanic)

Unknown/Wish not to answer

Other:

Required

Geographic Region *

Which region is consistent with your English dialect?

Southern

Western

North Central/Mid-Atlantic

North East

Rural (population <2,500)

Urban (population >2,500)

Required

Family medical history

Do you have any immediate family members (parents, siblings, children) with any of the following conditions:

Alzheimer's disease

Parkinson's disease

Vascular dementia (from stroke)

Dementia/severe memory impairment of unknown cause

Mild cognitive impairment

Hardening of the arteries

Arteriosclerosis of the brain

Other:

Do you provide care for a person with a significant illness? *

Yes

Do you have any speech, language or reading problems? (e.g., dyslexia, ADHD)? *

Yes

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