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.
(Required.)
Yes
No
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2.
Name
(Required.)
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3.
Gender
(Required.)
Male
Female
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4.
Where do you live?
(Required.)
Cambridgeshire
Norfolk / Suffolk
Other (please specify)
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5.
How would you prefer to be contacted?
(Required.)
Email
Telephone
Post
Please enter your email/telephone/address where you wish to be contacted
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?
(Required.)
Yes
No
If yes, please list them
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8.
Are you taking any medications?
(Required.)
Yes
No
If yes, please list them
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9.
Do you smoke?
(Required.)
Yes
No
If yes, how much per day roughly?
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10.
Do you drink alcohol?
(Required.)
Yes
No
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...)
(Required.)
Yes
No
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?
(Required.)
Yes
No
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13.
Have you ever been diagnosed with bipolar disorder, psychosis, or personality disorder?
(Required.)
Yes
No
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14.
Have you ever been diagnosed with anxiety disorder, panic disorder or obsessive compulsive disorder (OCD)?
(Required.)
Yes
No
If yes, please specify
15.
Have you ever been diagnosed with ADHD by a healthcare professional, either as a child or as an adult?
Yes
No
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)?
(Required.)
Yes
No
If yes, please provide further information
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18.
Are you allergic to any medications?
(Required.)
Yes
No
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?
(Required.)
Yes
No
Not Applicable
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20.
Have you ever had a major head injury that led to an inpatient hospital stay?
(Required.)
Yes
No
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?
(Required.)
Yes
No
If yes, please provide further information
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22.
Do you have any metallic implants in your body (e.g. a pacemaker)?
(Required.)
Yes
No
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23.
Do you have any metallic jewellery on your body that cannot be removed?
(Required.)
Yes
No