MRI Prescreener

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

AUhhwVSUfXyfNX5k7cTpJjZM9HtJP3KdGSGWGP52f64UyJ5whvjJHeLWatAtuR7Vbj5KaCVYTw9hLy6d2CzLDGoCLsd2YpIRXgzWSSX6FmMGBECrG

Hoglund Brain Imaging Center at the University of Kansas Medical Center supports the practice of protection for human subjects participating in research. We are conducting this short survey to determine if you are eligible to participate in our brain imaging project to help us understand how people learn new information about routine activities like doing laundry or washing dishes. The survey should take approximately 5 minutes.

Completion of the survey indicates your willingness to participate in this project and that you are at least age 18. If you are eligible we will contact you.

If you have any questions about the survey or experience technical difficulties please contact Dr. Bailey's lab at 785-532-6819.

If you have any additional questions about your rights as a research participant, you may call 913-588-1240, email humansubjects@kumc.edu or write the Human Subjects Committee, Mail Stop 1032, 3901 Rainbow Blvd, Kansas City, KS 66160.

Do you wish to continue the survey?

* must provide value

Yes

reset

Name

Phone

What is your preferred method of communication? Select all that apply.

Phone

Text

What time of day do you prefer to be contacted? Select all that apply.

8:00am-12:00pm

12:00pm-4:00pm

4:00pm-7:00pm

Other

Please list your preferred contact time.

What is your gender?

Male

Female

Other

reset

Age

Are you currently taking any prescription medications?

Yes

reset

Please list what medications, how often you take them, and what dose:

Expand

Which of the following have you been diagnosed with in the past?

Depression

Anxiety

Bi-polar disorder

Schizophrenia

ADD/ADHD

PTSD

OCD

Stroke

Brain tumor

Brain infection (e.g., encephalitis)

Parkinson's

Huntington's

Skull or facial fracture

Congestive heart failure

Diabetes

Cancer

Any other condition like these

NONE

If other, describe:

Expand

Have you experienced any symptoms of the condition(s) you indicated within the past 30 days?

Yes

reset

If yes, describe:

Expand

Have you ever had a concussion or been knocked unconscious (for example, due to a sports injury or car accident)?

Yes

reset

If yes, was the concussion diagnosed by a doctor?

Yes

reset

What happened and when? Did you experience any notable symptoms?

Expand

Do you have any metal implanted in your body surgically or accidentally?

Yes

reset

If yes, describe:

Expand

How did you find out about this study? Select all that apply.

Craigslist

Newspaper/Magazine

Flyer

Word of Mouth

Phonecall

Other

Please list how you found out about this study

Would you like to be contacted for future studies at KUMC that you might be eligible for?

Yes

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.