| Are you a United States citizen? |
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| Are you a Green Card holder? |
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No |
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| For HERA missions, are you willing to be confined and isolated for required periods of time: |
Yes |
No |
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| First Name: |
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| Middle Name: |
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| Last Name: |
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| Email Address: |
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| Are you currently between the ages of 28 and 55? |
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| Birthdate: |
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| Gender: |
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Female |
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| Are you a non-smoker? |
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No |
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| Height (in inches): For HERA missions, height not to exceed 6’ 2” |
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| Is you body mass index (BMI) between 18.5 and 30? |
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No |
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BMI = kg/m2 where kg is a person's weight in kilograms and m2 is their height in meters squared.
Body Mass Index (BMI): |
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| MRI - Do you have any metal in your body other than dental work or most joint replacements? |
Yes |
No |
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| Are you claustrophobic? |
Yes |
No |
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| Do you have any of the following? |
Allergies (including food) |
GI Disorders |
Dietary Limitations |
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| Any cardiovcascular issues? |
Yes |
No |
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| Any neurological problems? |
Yes |
No |
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| Any musculoskeletal problems? |
Yes |
No |
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| Are you taking any medications? |
Yes |
No |
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| Any sleep disorders such as sleep walking or use of sleep aids? |
Yes |
No |
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| Any psychiatric disorders or history of mental illness? |
Yes |
No |
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| Any motion sickness (not a disqualifier)? |
Yes |
No |
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| Any pharmacological treatment for ADHD? |
Yes |
No |
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| Any history of kidney stones? |
Yes |
No |
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| Any history of ulcers? |
Yes |
No |
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| Any history of epilepsy or other disorders of the brain? |
Yes |
No |
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| Any history of blood clots? |
Yes |
No |
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| Any history of close relatives with seizures? |
Yes |
No |
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| Are you currently on Bis-Phosphonate (for example, Fosamax, Boniva, or Reclast)? |
Yes |
No |
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| Are you currently on any medication that might increase chances of seizures? |
Yes |
No |
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| Do you have a military background? |
Yes |
No |
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| If yes, please provide a brief description of your military background: |
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| What is your highest level of education in a STEM related field? |
Bachelor |
Master of Science |
PhD |
Medical Doctor |
Other |
| Employment Status |
US Civil Servant |
Government Contractor |
Military |
Other |
Unemployed |
| Please provide any additional information you wish us to consider in your application |
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