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Required format:

PLEymysa9YhJh2VCYwAjZMMZSbqE

IPAT Patient Pre-Screening Eligibility

Thank you for your interest in the Impact of Intensive Treatment of Systolic Blood Pressure on Brain Perfusion, Amyloid, and Tau in Older Adults Study. Please complete the information below to determine eligibility for this study.

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Record ID

Timestamp:

M-D-Y H:M

1. Is English your preferred language?

Yes No

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1. Is your age between 60 and 80?

Yes No

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2. Do you feel you have more difficulty with your memory or thinking than in the past OR do you have a family history of dementia?

Yes No

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3. Would you be willing to allow the study physician to prescribe, provide, and manage Blood Pressure medications and work in conjunction with your Primary Care Provider for 2 years?

Yes No

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4. Do you have a flexible schedule and means of transportation to return to the research clinic for regular follow up visits?

Yes No

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5. Do you have a regular healthcare provider?

Yes No

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6. Have you been diagnosed with any of the following conditions? (Please select all that apply)

Alzheimer's disease or another type of dementia

Significant neurological disease such as Parkinson's disease

Significant visual or auditory problem

Seizure disorder

Multiple Sclerosis

History of severe head trauma

Normal pressure hydrocephalus

None of the above

7. Have you been diagnosed with any of the following autoimmune disorders? (Please select all that apply)

Systemic lupus erythematosus

Rheumatoid arthritis

Polymyalgia rheumatica

None of the above

8. Have you had a stroke, mini stroke, or Transient Ischemic Attack?

Yes

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9. Within the last 6 months, have you experienced or been diagnosed with any of the following conditions?

Heart attack

Congestive heart failure

Active atrial fibrillation

Cardiac arrest

Cardiac bypass procedures

Other severe heart issue

None of the above

10. Have you smoked cigarettes regularly in the last 12 months?

Yes No

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11. Are you claustrophobic or otherwise unable to undergo an MRI or PET/CT?

Yes No

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12. Have you been diagnosed with sleep apnea?

Yes No

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13. Are you currently enrolled or within the past two months were enrolled in another investigational drug or device study?

Yes No

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14. Based on the information entered above, you may be eligible to participate in the study. Do you consent to be contacted to learn more about this study?

Yes No

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14. Based on the information entered above, you are not eligible to participate in this study. If you would like to learn more about other studies, do you consent to be contacted?

Yes No

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16. Contact Information:

Email:

Phone Number:

Thank you for your time today. Please select 'Submit'.

Date Pre-screen form accessed: [HIDDEN]

M-D-Y

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