Brain blood flow, blood pressure and exercise

Participant Information

Please complete all the questions as accurately as possible.
We will only use your contact details to inform you, if you are eligible for this research project.
Your contact details and personal health information will remain strictly confidential. We will not give your details to anyone under any circumstances.

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* 1. Your contact details:

Full Name

Address

City/ Town

Postcode

State

Phone number

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* 2. Year of Birth

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* 3. Have you ever been diagnosed with any of these conditions?

	Yes	No	Not sure
Heart condition (including heart failure, or heart attack)	Heart condition (including heart failure, or heart attack) Yes	Heart condition (including heart failure, or heart attack) No	Heart condition (including heart failure, or heart attack) Not sure
Hypertension (high blood pressure)	Hypertension (high blood pressure) Yes	Hypertension (high blood pressure) No	Hypertension (high blood pressure) Not sure
Stroke	Stroke Yes	Stroke No	Stroke Not sure
Traumatic brain injury	Traumatic brain injury Yes	Traumatic brain injury No	Traumatic brain injury Not sure
Carotid Stenosis	Carotid Stenosis Yes	Carotid Stenosis No	Carotid Stenosis Not sure
Photosensitive Epilepsy	Photosensitive Epilepsy Yes	Photosensitive Epilepsy No	Photosensitive Epilepsy Not sure

Other (please specify)

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* 4. Please list any medications or supplements that you are prescribed or take regularly:

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* 5. Please tell us about your health habits and risk factors.

	Yes	No	Not sure
Do you smoke cigarettes, or have you quit in the last 6 month?	Do you smoke cigarettes, or have you quit in the last 6 month? Yes	Do you smoke cigarettes, or have you quit in the last 6 month? No	Do you smoke cigarettes, or have you quit in the last 6 month? Not sure
Do you consider yourself to be physically active?	Do you consider yourself to be physically active? Yes	Do you consider yourself to be physically active? No	Do you consider yourself to be physically active? Not sure
Do you eat a healthy diet?	Do you eat a healthy diet? Yes	Do you eat a healthy diet? No	Do you eat a healthy diet? Not sure

Other (please specify)

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* 6. Which gender are you?

Male

Female

X (Indeterminate/Intersex/Unspecified)

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* 7. Is this different from the sex you were assigned at birth?

Yes

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* 8. Females only: are you currently pre or postmenopausal?

Premenopause

Perimenopause (Menopausal transition)

Postmenopause (1 year since last menstrual bleeding)

I am not sure

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* 9. Females only: are you currently undergoing hormone replacement therapy or taking any other hormone supplements (estradiol, contraceptive pill etc.) ?

Yes

Other (please specify)