Pesquisas em tratamentos neurodegenerativos com inteligência artificial

General guidelines. If you are unable to complete this form alone, ask someone else for help. I am aware that the information provided here is true, so please do so carefully.*

YES

NO

I authorize Neurocognitera to use my information for research purposes on neurodegenerative diseases as well as future contacts.*

Yes

No

I declare that I have read and agree to the Terms and Conditions of Use and the Privacy Policy.*

Yes, I read it and I agree.

1-) Your full name*

Name of the person who helped with the completion. (note: leave blank if there is no name)

2-) Your email*

3-) Whatsapp *

4-) Country:*

5-) City:*

6-) Date of Birth: MM/DD/YYYY*

7-) Sex:*

Masculine

Feminine

8-) How tall are you ( " )?*

9-) What is your Weight (lbs)?*

10-) Ethnicity/Racial Origin:*

White

Black/Afro-descendant

Brown

Indigenous

Asian

Hispanic/Latino

Middle Eastern/North African Descent

Mixed race (combination of two or more racial origins)

Other

11-) Do you have biological children?*

Yes

No

12) Marital Status*

Single

Married

Divorced

Widower

Stable Union

I prefer not to inform

13-) What is the name/type of neurodegenerative disease you have?*

14-) How long has it been since you were diagnosed?*

15-) What symptoms are you currently experiencing?*

16-) Mark below if you have other associated health conditions? *

Diabetes

hypertension

Obesity

Dyslipidemia (high blood cholesterol)

Depression

Sleep apnea

Cardiovascular diseases

I don't have any

Other (Write the name below)

.

17-) Family history of neurodegenerative diseases?

Yes

No

I don't know how to answer (I don't know my biological parents, etc.)

18-) What treatments or medications have you used?

19-) Are you currently undergoing any treatment? (If so, which ones?)

20-) How do you rate the effectiveness of the treatment(s)? (from 0 to 10)

21-) Mark below if you have done or are doing any alternative treatment?

Physiotherapy

Phytotherapeutics

Infrared light

Neuromodulation

Yoga

Omega 3

Acupuncture

Meditation

I do not do alternative treatment

Other (write the name of the treatment below)

.

22-) How do you rate the effectiveness of the alternative treatment(s)? (from 0 to 10?)*

23-) Have you ever participated in any clinical study?*

Yes

No

24-) Do you smoke?*

Yes

No

Sometimes

I smoked in the past, but I stopped.

25-) Do you drink alcoholic beverages?*

Yes

No

Sometimes

Yes, in the past but I stopped

26-) Do you practice physical activities regularly?*

Yes

No

Sometimes

Yes, in the past but I stopped

27-) What is your main diet like? What are the main foods you eat?*

28-) How many meals do you eat a day?

29-) How many hours, on average, do you sleep per day?*

30-) What is your blood type?

A+

A-

B+

B-

AB+

AB-

O+

O-

I don't know

31-) What is your main diet like? What are your main foods? How many meals do you eat per day?*

32-) Do you have any allergies to medication(s) or food(s)?*

33-) Mark below the exams you have*

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT)

Cerebrospinal Fluid (CSF)

Electroencephalogram (EEG)

PET/Brain Scintigraphy

Neuropsychological Examinations

Genetic Tests

SPECT (Single Photon Emission Computed Tomography)

Blood Tests for Biomarkers

Transcranial Ultrasonography

Cerebral Angiography

Study of Evoked Potentials

Diffusion Tensor Imaging (DTI)

Smell Test

Electromyography (EMG)

I don't have/I haven't had any exams

I can't say

Other exams (tell us in the comments below which exams you have)

34-) This space is for general comments.

SIGN-UP

Neurocognitera technology in health