Pre-screening form for Cognition Research of Cambridge (COGCAM)

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* 1. I consent to be contacted by Dr Chamberlain's Research Team at the University of Cambridge about studies that may be of interest to me.
I understand that my information will be treated confidentially and will not be shared with anyone outside the research team.

Yes

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* 2. Name

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* 3. Gender

Male

Female

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* 4. Where do you live?

Cambridgeshire

Norfolk / Suffolk

Other (please specify)

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* 5. How would you prefer to be contacted?

Telephone

Post

Please enter your email/telephone/address where you wish to be contacted

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* 6. In what year were you born? (enter 4-digit birth year; for example, 1986)

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* 7. Do you have any medical conditions?

Yes

If yes, please list them

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* 8. Are you taking any medications?

Yes

If yes, please list them

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* 9. Do you smoke?

Yes

If yes, how much per day roughly?

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* 10. Do you drink alcohol?

Yes

If yes, how many units of alcohol do you drink per week, on average? (e.g. a large glass of wine, or pint of beer, counts as two units. A single shot of spirit is one unit)

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* 11. Have you used any illicit substance(s), in the past six months? (e.g. cannabis, cocaine, ecstasy...)

Yes

Prefer Not To Say

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* 12. Have you felt depressed and down, most of the day, nearly every day, for the past week?

Yes

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* 13. Have you ever been diagnosed with bipolar disorder, psychosis, or personality disorder?

Yes

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* 14. Have you ever been diagnosed with anxiety disorder, panic disorder or obsessive compulsive disorder (OCD)?

Yes

If yes, please specify

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* 15. Have you ever been diagnosed with ADHD by a healthcare professional, either as a child or as an adult?

Yes

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* 16. Are you taking any medications?

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* 17. Have you ever been diagnosed with a mental health condition by a professional (such as your doctor)?

Yes

If yes, please provide further information

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* 18. Are you allergic to any medications?

Yes

If yes, please provide further information

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* 19. If you are female we will ask you to use highly effective contraception during the study. Examples of highly effective contraception include implants, injectables, combined oral contraceptives, some intrauterine devices or having a vasectomised partner. Would you agree to this?

Yes

Not Applicable

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* 20. Have you ever had a major head injury that led to an inpatient hospital stay?

Yes

If yes, please provide further details

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* 21. Have you taken part in any similar research studies in the last three months?

Yes

If yes, please provide further information

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* 22. Do you have any metallic implants in your body (e.g. a pacemaker)?

Yes

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* 23. Do you have any metallic jewellery on your body that cannot be removed?

Yes

Question Title

* 1. I consent to be contacted by Dr Chamberlain's Research Team at the University of Cambridge about studies that may be of interest to me. I understand that my information will be treated confidentially and will not be shared with anyone outside the research team.

Question Title

* 2. Name

Question Title

* 3. Gender

Question Title

* 4. Where do you live?

Question Title

* 5. How would you prefer to be contacted?

Question Title

* 6. In what year were you born? (enter 4-digit birth year; for example, 1986)

Question Title

* 7. Do you have any medical conditions?

Question Title

* 8. Are you taking any medications?

Question Title

* 9. Do you smoke?

Question Title

* 10. Do you drink alcohol?

Question Title

* 11. Have you used any illicit substance(s), in the past six months? (e.g. cannabis, cocaine, ecstasy...)

Question Title

* 12. Have you felt depressed and down, most of the day, nearly every day, for the past week?

Question Title

* 13. Have you ever been diagnosed with bipolar disorder, psychosis, or personality disorder?

Question Title

* 14. Have you ever been diagnosed with anxiety disorder, panic disorder or obsessive compulsive disorder (OCD)?

Question Title

* 15. Have you ever been diagnosed with ADHD by a healthcare professional, either as a child or as an adult?

Question Title

* 16. Are you taking any medications?

Question Title

* 17. Have you ever been diagnosed with a mental health condition by a professional (such as your doctor)?

Question Title

* 18. Are you allergic to any medications?

Question Title

* 19. If you are female we will ask you to use highly effective contraception during the study. Examples of highly effective contraception include implants, injectables, combined oral contraceptives, some intrauterine devices or having a vasectomised partner. Would you agree to this?

Question Title

* 20. Have you ever had a major head injury that led to an inpatient hospital stay?

Question Title

* 21. Have you taken part in any similar research studies in the last three months?

Question Title

* 22. Do you have any metallic implants in your body (e.g. a pacemaker)?

Question Title

* 23. Do you have any metallic jewellery on your body that cannot be removed?

* 1. I consent to be contacted by Dr Chamberlain's Research Team at the University of Cambridge about studies that may be of interest to me.
I understand that my information will be treated confidentially and will not be shared with anyone outside the research team.