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Cognitive Aging Study: detailed screening form
***If you have a COCHLEAR IMPLANT, DEFIBRILLATOR or PACEMAKER you are NOT ELIGIBLE***
Based on our initial screening, you may be eligible for our study. This is a more detailed screening form. Please read every question carefully. It should only take a few minutes.
Please be aware that if your body weight is above 240 pounds, you will probably not fit comfortably into our scanner.
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* Indicates required question
What is your email address?
*
Your answer
What is your phone number?
*
Your answer
What is your name?
*
Your answer
What is your age?
*
Your answer
Are you fluent in English?
Yes
No
Other:
Clear selection
What is your racial identity? This is free-form, please self-describe as you see fit.
Your answer
What is your approximate household monthly income?
Your answer
Do you think you may have any kind of metal in your body?
*
Your answer
Have you ever had an MRI before? If so, please give the approximate date and place.
*
Your answer
Have you ever been to the Cornell MRI facility before? If so, please give the approximate date.
Your answer
Please list all surgical procedures and approximate date (year only is fine). If you haven't had any, put "none".
*
Your answer
Do you have any implanted electrical device of any kind?
*
Yes
No
Other:
Is there any possibility that you are pregnant?
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Yes
No
Not applicable
Other:
Do you have a hearing aid?
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Yes
No
Other:
Do you have hair extensions, permanent makeup, tattoos, or body piercings with jewelry you cannot remove? Most tattoos are MRI safe, but we need to be sure - some could lead to burns. Please note that we do not scan individuals who have tattoos directly on the face due to the possibility of burns.
*
Yes
No
Other:
Do you have a cardiac pacemaker, pacemaker wires, external cardiac monitor or external cardiac wires? Do you have an implanted cardioinverted defibrillator (ICD)? Do you have an artificial heart valve?
*
Yes
No
Other:
Do you have a catheter, a feeding tube, radiation seeds, or any kind of medication patch?
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Yes
No
Other:
Do you have an implanted neurostimulator (deep brain stimulator) or any other kind of stimulator?
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Yes
No
Other:
Do you have surgical staples, mesh, metallic clips or metallic sutures? Do you have a bone/joint pin, screw, nail, wire, plate, or similar?
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Yes
No
Other:
Do you have dentures, braces, ocular implants, scleral buckle, eyelid spring, ear implants of any kind, or any breathing or motion disorder?
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Yes
No
Other:
Do you have a tissue expander or any kind of prosthesis (including eye, penile, limb, etc.),
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Yes
No
Other:
Do you have an aneurysm clip?
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Yes
No
Other:
Do you have an implanted port or drug diffusion device?
*
Yes
No
Other:
Do you have a stent, filter, coil, valve, shunt or programmable shunt?
*
Yes
No
Other:
If you answered yes to any of the questions above, please explain below. If you did not answer yes to any questions, please write "NA".
*
Your answer
If you are eligible for participation, or we need to follow up about specific questions, how would you like to be contacted?
Email me
Text me
Call me on the phone
Other:
Clear selection
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