Beacon Interest — Brain & Nerves

Who is completing this form?

Myself Parent/legal guardian Spouse/partner Other caregiver

Full name

Email address

Mobile phone number

US format; used for SMS + call

Preferred contact method

Phone call Text message Email

Best time to reach you

Morning Afternoon Evening Anytime

Date of birth

Derives age for eligibility.

Sex assigned at birth

Female Male Intersex Prefer not to say

Gender identity (optional)

Woman Man Non-binary Prefer to self-describe Prefer not to say

City and state

ZIP / postal code

Primary geo-match signal.

How far would you travel for a study?

Under 10 mi 10–25 mi 25–50 mi 50+ mi Remote/at-home only

Preferred language

English Spanish Other

Preferred language (other)

I agree to be contacted about future research opportunities that may fit me.

I agree to be contacted about future research opportunities.

I have read the privacy notice and understand my information is stored securely and I can opt out anytime.

I have read and accept the privacy notice.

Which apply? Choose any.

Other neurological condition (please specify)

Diagnosed by a neurologist?

Yes No Not sure

Time since diagnosis

Under 1 yr 1–3 yrs 3–10 yrs 10+ yrs

Current neurological medications

Headache days per month

0–3 4–7 8–14 15+ (chronic)

Do you get aura (visual/sensory warning)?

Yes No Sometimes

On a preventive medication?

Yes No

[Memory] Current stage

Mild Moderate Severe Not sure

[Memory] Known cognitive test score (MoCA/MMSE), if any

Optional. Often completed by a caregiver.

[Parkinson's] On levodopa/carbidopa?

Yes No

[Parkinson's] Do you experience 'off' periods / motor fluctuations?

Yes No Not sure

[MS] Type

Relapsing-remitting Secondary progressive Primary progressive Not sure

[MS] Relapse in the past 12 months?

Yes No

[MS] Mobility

No aid Cane Walker Wheelchair

[Epilepsy] Seizure frequency

Daily Weekly Monthly A few per year Seizure-free 1yr+