Center for Imaging Research

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Enrollment Form

Thank you for taking the time to answer these screening questions. We ask about your health information because we want to scan subjects and give them an anesthetic agent in the safest manner possible. Therefore, most of the below questions are required. You will receive an error message, if you miss one.

Please note that this is a secure questionnaire that will only be available to the study coordinator, Kathryn K. Lauer, MD, or her anesthesiologist designee, and Anthony G. Hudetz, PhD.

Questions

If you have any questions about the form, or if you are having trouble submitting it, please do not hesitate to call the study coordinator, Carrie O'Connor, at 414-955-4956.

Consent Form

Did you read and submit the consent necessary to fill out this form?  Yes  No

If no, please go to the consent page, read it and submit.

Background

Where did you hear about this study? 

If "Other," please specify.

First Name                 Last Name

Email                         Sex   Female  Male

Address1       Address2

City     State    Zip code       Date of Birth 

Home telephone number    Weight (pounds)      Height (inches)

Work telephone number 

Days/Times of day available for scanning  

Best time to contact                                

Race/Ethnicity

What is your racial background? (Feel free to check as many boxes as necessary)

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America [including Central America], and who maintains tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)

Other  If other, please describe. 

Are you Hispanic or Latino Yes  No

Education/Occupation

How many years of education do you have?   Any degrees?

Describe your current occupation. 

Health Questions

Please list any allergies (if you don't have any, please write "none.") 

Are you seeing a doctor for a particular medical condition? If so, please list: 

Have you ever had surgery? If so, for what? 

Did you or your family have any problems with anesthesia?

How much activity can you do?

Can you walk up one flight of stairs?  Yes  No

Have you ever been evaluated for tuberculosis?   Yes  No

If yes, please describe.

Do you have asthma?  Yes  No

Do you have chronic obstructive pulmonary disease?  Yes No

If yes, please describe.

Have you ever been evaluated for any other lung issues?  Yes  No

If yes, please describe.

Do you have sleep apnea?  Yes  No

Do you have high blood pressure?  Yes  No

Have you ever been evaluated for a heart attack?  Yes  No

If yes, please describe.

Have you ever had palpitations or fluttering in the chest?  Yes  No

Have you ever considered yourself to be claustrophobic?  Yes  No

Have you ever suffered from insomnia or had trouble sleeping? Yes No

Have you ever been diagnosed with or thought you might have attention deficit disorder (ADD)?  Yes  No

Have you ever been evaluated for a possible neurological disorder?  Yes  No

If yes, please describe.

Have you ever been evaluated for a possible psychological disorder?  Yes No

If yes, please describe.

Have you ever had a head injury with a loss of consciousness?  Yes  No

If yes, please describe and include the length of time.

Have you ever had seizures?  Yes  No

If yes, please describe.

Have you ever had fainting spells?  Yes  No

If yes, please describe.

Have you had a stroke?  Yes  No

Have you ever been evaluated for a brain tumor?  Yes  No

If yes, please describe.

Have you ever had cancer?  Yes No

If yes, please describe.

How was your cancer treated?

Have you had kidney disease?  Yes  No

If yes, please describe.

Do you suffer from headaches?  Yes  No

If yes, please select the type(s) of headache you've had. Migraine Cluster Tension

Are you currently taking ANY medications?  Yes  No

If yes, please enter the names of the medications that you are taking.

Do you drink caffeine?  Yes  No

If yes, how many drinks (cups of coffee/soda/tea) per day on the average?

Do you smoke?  Yes No

How many years have you smoked?

How many cigarettes/pipes/cigars per day on the average?

Do you drink alcohol?  Yes No

If yes, how many drinks per week on the average?

Do you use recreational drugs?  Yes No

Have you ever been treated (or thought that you needed treatment) for alcohol or drug abuse?  Yes No

Do you have any metal in your body (pacemaker, plates, clips, pins, pellets, etc.)?  Yes No

Do you have any body piercings with nonremovable jewelry or hardware?  Yes No

Do you have any tattoos on your scalp, face or neck?  Yes No

Do you wear glasses or contacts? Yes No

Please check:  Glasses Contacts Both

Are you nearsighted or farsighted?

Do you know your prescription?

Do you now or have you ever had a vision problem that was not correctable with glasses?  Yes No

If yes, please explain and indicate if the problem still exists.

Are you color blind?  Yes No

Do you have an astigmatism?  Yes No

Do you have a lazy eye (amblyopia)?  Yes No

Can you stare at an object without moving your eyes for five seconds or more?  Yes  No

Do you have any hearing loss?  Yes  No

Are you or could you possibly be pregnant?  Yes  No

Do you wear braces, orthodontic retainers, partials or dentures?  Yes  No

Handedness Information

What is your dominant hand?

What is the dominant hand of your:

Mother   Maternal grandmother   Maternal grandfather

Father    Paternal grandmother    Paternal grandfather

Handedness Inventory

For the following activities, please indicate your hand preference by selecting the most appropriate description of the hand you would use. Some activities require both hands. In these cases, more explicit information is in parentheses.

Key:
AL = Always Left, Never Right
PL = Prefer Left
NP = No Preference
PR = Prefer Right
AR = Always Right, Never Left

Please answer all the questions.

Writing 

Drawing   

Throwing

Scissors 

Toothbrush

Knife (without fork)

Broom (upper hand)

Striking a match

Opening a box (lid)

Foot used for kicking

Preferred eye when using one (e.g., looking into a camera window)
 

 

 

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Page Updated 08/14/2014