Eligibility to Participate in the BRAIN Training Study

Please note that by completing this questionnaire, you consent to us collecting your answers to the questions, including your contact information. All information you provide in this questionnaire will be held in strict confidentiality, and shared only with the research centre conducting the study.

If you complete this questionnaire, you will be contacted via telephone by a member of the research team. They will (a) confirm your eligibility, (b) answer any questions you have, and (c) if you would like to move forward, gather information regarding your medical history to make sure it is safe for you to take part in this study. If you are found to be potentially eligible to participate they will book a time for you to come into the research centre.

By clicking Next, you are agreeing to participate. You can stop this survey at anytime by exiting the survey prior to completion.

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* 1. Full Name

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* 2. Date of Birth

Date / Time

Date

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* 3. Gender

Female

Male

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* 4. Phone Number

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* 5. Email Address

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* 6. Postcode

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* 7. What is the best time to contact you?

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* 8. Are you currently exercising once a week or more?

Yes

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* 9. Please answer the following questions:

	Yes	No	Don't Know
Have you noticed any difficulties with your memory?	Have you noticed any difficulties with your memory? Yes	Have you noticed any difficulties with your memory? No	Have you noticed any difficulties with your memory? Don't Know
Have you been concerned about your memory?	Have you been concerned about your memory? Yes	Have you been concerned about your memory? No	Have you been concerned about your memory? Don't Know
Have you mentioned any concerns about memory to anymore?	Have you mentioned any concerns about memory to anymore? Yes	Have you mentioned any concerns about memory to anymore? No	Have you mentioned any concerns about memory to anymore? Don't Know
Have others commented on your memory?	Have others commented on your memory? Yes	Have others commented on your memory? No	Have others commented on your memory? Don't Know
Have you seen a GP, specialist or other health professional about your memory?	Have you seen a GP, specialist or other health professional about your memory? Yes	Have you seen a GP, specialist or other health professional about your memory? No	Have you seen a GP, specialist or other health professional about your memory? Don't Know
Are you able to attend the research site for supervised exercise training 3 times per week for 12 months? Each session will last between 30-60 minutes depending on the exercise group you are allocated to.	Are you able to attend the research site for supervised exercise training 3 times per week for 12 months? Each session will last between 30-60 minutes depending on the exercise group you are allocated to. Yes	Are you able to attend the research site for supervised exercise training 3 times per week for 12 months? Each session will last between 30-60 minutes depending on the exercise group you are allocated to. No	Are you able to attend the research site for supervised exercise training 3 times per week for 12 months? Each session will last between 30-60 minutes depending on the exercise group you are allocated to. Don't Know
Are you willing to be contacted over the phone by a member of the research team?	Are you willing to be contacted over the phone by a member of the research team? Yes	Are you willing to be contacted over the phone by a member of the research team? No	Are you willing to be contacted over the phone by a member of the research team? Don't Know
Have you been diagnosed with dementia? This includes any type of dementia, such as Alzheimer's disease, Vascular dementia, Lewy Body dementia and Frontotemporal dementia.	Have you been diagnosed with dementia? This includes any type of dementia, such as Alzheimer's disease, Vascular dementia, Lewy Body dementia and Frontotemporal dementia. Yes	Have you been diagnosed with dementia? This includes any type of dementia, such as Alzheimer's disease, Vascular dementia, Lewy Body dementia and Frontotemporal dementia. No	Have you been diagnosed with dementia? This includes any type of dementia, such as Alzheimer's disease, Vascular dementia, Lewy Body dementia and Frontotemporal dementia. Don't Know
Have you been diagnosed with a progressive neurological disease such as Parkison's disease, Multiple sclerosis, Huntington's disease etc.?	Have you been diagnosed with a progressive neurological disease such as Parkison's disease, Multiple sclerosis, Huntington's disease etc.? Yes	Have you been diagnosed with a progressive neurological disease such as Parkison's disease, Multiple sclerosis, Huntington's disease etc.? No	Have you been diagnosed with a progressive neurological disease such as Parkison's disease, Multiple sclerosis, Huntington's disease etc.? Don't Know
Can you walk at least the length of the room without the assistance of another person?	Can you walk at least the length of the room without the assistance of another person? Yes	Can you walk at least the length of the room without the assistance of another person? No	Can you walk at least the length of the room without the assistance of another person? Don't Know
Have you had 2 or more strokes?	Have you had 2 or more strokes? Yes	Have you had 2 or more strokes? No	Have you had 2 or more strokes? Don't Know

Thank you very much for taking the time to fill out the BRAIN Study eligibility survey.
A member of the research team will contact you shortly or you can contact them if you would prefer. Relevant details are below:

Contact Name: Isabel Shih
Contact Phone Number: 02 9036 7418
Contact Email: fhs.brainstudy@sydney.edu.au

Once again, thank you for your time.