Golby Lab, A Surgical Brain Mapping Laboratory
Golby Lab Research Fund
People

Participant Recruitment Form

We will use your answers to the following questions about your personal and medical history to identify which, if any, of our ongoing studies you would be approproate for. Your responses will be treated with the strictest confidentiality.

Questions? contact us at mri.brain.imaging@gmail.com or call 617-732-5883.


First Name
Last Name
Email
Home Phone
Mobile Phone
Work Phone
Preferred Contact Method(s)
How did you hear about our research?
Current Height  
Current Weight
Current Age
Date of Birth
Do you have a social security and/or taxpayer identification number?
Please list the languages that you learned to speak before age five: Language 1:

Language 2:

Language 3:
What is your dominant hand?

Do you experience claustrophobia?
Have you ever been diagnosed with respiratory disease?
Have you ever bene diagnosed with heart disease?
Have you ever had a head injury with the loss of consciousness?
Have you ever been diagnosed with a psychological disorder?
Have you ever been diagnosed with a neurological disorder?
Have you ever been diagnosed with a learning disability or been enrolled in special education classes?
Have you ever been diagnosed with an attention deficit?
Have you ever been treated for or thought you might need treatment for an alcohol or drug addiction?
Have you ever had metal fragments in the eye, or are you a metal worker?
Do you have non-removable metal objects on/in your body (e.g., cardiac pacemaker, cochlear implants, implanted medication pump, plates, pins, rods, joints, etc.)?
Do you require vision correction?
 

Questions? contact us at mri.brain.imaging@gmail.com or call 617-732-5883.