BrainHealth Project: Imaging Interest Form

First Name

Last Name

Date of Birth (enter YYYY-MM-DD on keyboard)

Email

Phone

Gender MaleFemaleOther

I am 18 years old or older truefalse

I do not have a history of claustrophobia truefalse

No history of breathing disorder truefalse

I do not have a permanent retainer truefalse

I do not have any implants that contain metal truefalse

I weigh less than 250lbs (to accommodate the fMRI table) truefalse

I do not have tattooed makeup (includes microblading) truefalse

I am interested in completing online training and assessments truefalse

I am interested in coming in person for the fMRI scans truefalse

How did you hear about us? Instagram Facebook Through a Friend BrainHealth Event Other

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