Stark Lab

Cognitive Neuroscience of Learning and Memory

MRI Screening Questionnaire

In order to participate in our fMRI studies fill out and submit the following questionnaire. If you qualify, one of our researchers will contact you to schedule an appointment. If you have concerns regarding the submission of this information online, we completely understand. You can also give us a call at (949) 824-4230 and we will go through the questionnaire with you over the phone instead.

Please remember that fields marked with * are required.

Your Name: *

Your Email address: *

Telephone number: *

Street Address, City, State, Zip: *

Date of Birth: *

Handedness: *
Right
Left

Native English speaker? *
Yes
No

Race: *
American Indian
Asian
Black
Pacific Islander
White
Other

Ethnicity: *
Hispanic
NonHispanic

What is your highest degree of education completed? *
High school graduate or equivalent
Two-year college degree
Four-year college degree
Master's degree
Doctoral degree +

Are you color blind? *
Yes
No

How did you hear about our reseach? *

Are you currently on any medications? *
Yes
No

If Yes, please summarize below:

Do you have corrected vision? *
No
Yes, I wear glasses
Yes, I wear contacts

If you wear glasses, can you recognize someone's face as they enter the room without them?
Yes
No

Do you use a removable hearing aid? *
Yes
No

If Yes, how good is your hearing without it?
OK
Somewhat OK
Not OK

MRI: Do you have a cardiac pacemaker, implanted cardiac defibrillator? *
Yes
No

MRI: Do you have any surgical clips, staples, aneurysm clips, neurostimulators, shunts, or implanted wires? *
Yes
No

MRI: Do you have any eye or inner ear implants, artificial ear valve or any medical implanted devices? *
Yes
No

MRI: Do you have any implanted pumps, e.g. insulin pump, drug infusion pump, or vascular access port? *
Yes
No

MRI: Do you have artificial limbs, joint replacements, metal bone screws, rods or plates? *
Yes
No

MRI: Do you have braces or any other metal in your mouth? *
Yes
No

MRI: Do you have any irremovable piercings? *
Yes
No

MRI: Do you have a diaphragm, intra-uterine device (IUD) or penile prosthesis? *
Yes
No

MRI: Do you have any head or neck tattoos or tattooed (permanent) makeup? *
Yes
No

MRI: Do you have any BBs, bullets, or shrapnel? *
Yes
No

MRI: Have you ever had a facial injury from metal or had metal removed from your eye(s)? *
Yes
No

If yes to any of the MRI metal contraindications, please explain below:

Are you pregnant or trying to become pregnant? *
Yes
No

Do you have a history of asthma or difficulty breathing? *
Yes
No

Have you ever had an MRI before? *
Yes
No

If yes, approximately how long ago did you have it?
0-6 months ago
1-2 years ago
3-5 years ago
More than 5 years ago

Have you ever had a head injury in which you lost consciousness for more than 5 minutes? *
Yes
No

Are you claustrophobic (uncomfortable in enclosed spaces)? *
Yes
No

Do you smoke more than one pack of cigarettes a day? *
Yes
No

Do you frequently consume more than 14 alcoholic drinks per week? *
Yes
No

Have you ever used Ecstasy, PCP, LSD, Meth (Speed), Cocaine or Heroin? *
Yes
No

Have you ever had a problem with addiction to or abuse of any drug (including alcohol or marijuana)? *
Yes
No

Do you have any medical conditions such as HIV, diabetes, glaucoma, tuberculosis, or emphysema? *
Yes
No

Have you ever been diagnosed with Parkinson's disease, multiple sclerosis, migraines, cyst, tumor, or aneurysm in the brain or any other neurological disorder? *
Yes
No

Have you ever had a stroke? *
Yes
No

Have you ever been diagnosed as having attention-deficit hyperactivity disorder, dyslexia, major clinical depression, or any other mental health problem or psychiatric disorder? *
Yes
No

If you have any medical conditions that we have not covered that you would like to mention, please use the space below to describe.