Volunteer Participant Information

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Gender
Ethnicity
years old
Are you right-handed?
Lbs.
Are you currently employed?
Are you currently a student?
What is your highest level of education?
Have you had a bad cold or the flu in the last month?
Do you take any medications on a regular basis?
Do you have any allergies (including to eggs or latex)?
What are the symptoms of your allergies?
Check all that apply.
(Please give details of the symptoms checked above.)
Have you had asthma or bronchitis?
How often do you get asthma?
What seems to trigger your asthma attacks?
Have you needed any medication for asthma in the last three months?
Check All That Apply
Did you receive any treatment?
Is it still active?
Are you still taking treatment?
Type of Hepatitis
Did you receive any treatment?
Is it still active?
Did You Have
How often do you get headaches?
What kind of headaches are they?
Location of Headaches
What symptoms do you have? (Check all that apply)
What seems to trigger them?
Do you consider yourself more anxious than the average person?
Have you ever had a panic / anxiety attack?
How often do you have anxiety attacks?
What seems to set them off? Trigger situations?
Are you currently receiving any treatment for anxiety?
Do you exercise on a regular basis?
How would you rate your ability to exercise?
Check All That Apply. Have Your Ever
(Fell off bike, fell off horse, playing hockey, hit in the head with a baseball bat, car accident, etc.)
Seconds / Minutes / Longer
Had to stay in hospital?
(For example, skull x-ray, CAT or MRI scan, EEG)
Had to be observed overnight in home?
(Woken up every hour by parents, spouse, etc. during the night)
Any problems following head injury?
(Headaches, nausea, dizziness, seizures)
(For example, no sports for weeks / months)
Any medical follow-up necessary?
Have you ever needed to visit an emergency room, or be admitted to a hospital?
Have you ever had anesthesia?
Any adverse reactions to the anesthesia?
Have you had prior experience in medical research?