Peanut Cognition Study Screening Form | School of Public Health

You can let us know if you are interested in the study by any of the following 3 ways:

Fill out the screening form below.
Send us an email to [email protected]
Call us at 909-558-8382

Name

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Cell Phone Number

Preferred Method of Contact

Gender

Date of Birth

Height in Feet and Inches

feet

inches

Weight

The following information is needed to properly assess your qualification to participate in the Peanut Cognition Study conducted by Loma Linda University and will be used per Study Protocol guidelines.

Do you have any of the following conditions?
(can check multiple) (select each applicable text)

High Cholesterol and/or taking cholesterol medication

High Blood Pressure and/ or taking BP medication

High Blood Sugar

Heart Disease

None of the above

Do you have a pacemaker?

Do you have concerns about your memory?

Do you think your memory is worse than others that are your age?

Are you claustrophobic?

Are you allergic to Peanuts?

If not allergic to peanuts, how often do you eat them?

Are you allergic to any other nuts?

If not allergic to nuts, how long have you eaten them?

If yes, which nuts are you allergic to?

Upon reviewing the information you provided, we will inform you of your eligibility to attend our study information session which is the next step in the process to identify eligible participants. In order to reach you with this information, please indicate the best times to reach you: