Download fMRI screening form - Harvard Wiki

fMRI screening form
Thank you for your interest in participating in our study. If you wish to participate,
please fill out the screening questions below. These questions will help us determine
whether you are eligible for our study. After reviewing your responses we will contact
you to set up a session when one becomes available. Please respond as honestly as
possible to these questions. Thanks! All information you provide is stored on a
password-encrypted server accessible only by researchers at the Computational
Cognitive Neuroscience Lab at Harvard University. Please send any questions/concerns
regarding this survey to Sam Gershman, [email protected].
Q1. What is your full name?
Q2. Please enter your email address:
Q3. Please enter your phone number:
Q4. What is your age?
Q5. What is your gender?
Q6. Please answer the following questions.
Yes (1)
No (2)
Are you right handed? (1)
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Are you a native English
speaker? (2)
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Do you wear a permanent
retainer? (3)
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Do you have any metal in
your body (such as surgical
screws or plates)? (4)
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Do you have a surgical
aneurysm clip? (5)
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Do you wear any metal
jewelry that you cannot (or
wish not to) remove for the
scan? (6)
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Do you have a bridge or
have dental wires or other
metal (not counting dental
fillings)? (7)
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Do you have dentures? (8)
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Do you have a tattoo? (9)
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Are you claustrophobic? (10)
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Have you ever had a head
injury? (11)
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Have you ever had a
seizure? (12)
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Do you have a history of
problems with your ears?
(13)
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Do you have a learning
disorder? (14)
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Do you have a history of any
emotional or psychiatric
illness? (15)
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Are you currently depressed,
or taking any medication for
depression? (16)
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Do you have any breathing
problems? (17)
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Are you pregnant? (18)
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Are you breast feeding? (19)
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Do you have a pacemaker?
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(20)
Do you have a prosthetic
heart valve? (21)
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Do you have a
neurostimulator? (22)
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Do you have implanted
pumps? (23)
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Do you have cochlear
implants? (24)
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Do you have a hearing aid?
(25)
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Do you have an IUD? (26)
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Have you sustained an eye
injury that might have
resulted in any metal in your
eye? (27)
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Do you have Meniere's
Diseas? (28)
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Have you previously
participated in an MRI scan?
(29)
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Do you have any shrapnel in
your body? (30)
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Are you wearing a skin
patch (nicotine,
contraceptive)? (31)
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Have you had a bone
treated with metal rods,
plates or screws? (32)
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Do you have hair
extensions? (33)
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Thank you for your interest in our studies. A researcher will contact you via email if you
are eligible to participate in an upcoming fMRI scan.