Participant Recruitment Form

First Name

Last Name

Email

Home Phone

Mobile Phone

Work Phone

Preferred Contact Method(s)

How did you hear about our research?

Current Height

feet

inches

Current Weight

pounds

Current Age

Date of Birth

month

day

year

Do you have a social security and/or taxpayer identification number?

Yes
No

Please list the languages that you learned to speak before age five:

Language 1:

Language 2:

Language 3:

What is your dominant hand?

left-handed
right-handed
ambidextrous

Do you experience claustrophobia?

Yes
No

Have you ever been diagnosed with respiratory disease?

Yes
No

Have you ever bene diagnosed with heart disease?

Yes
No

Have you ever had a head injury with the loss of consciousness?

Yes
No

Have you ever been diagnosed with a psychological disorder?

Yes
No

Have you ever been diagnosed with a neurological disorder?

Yes
No

Have you ever been diagnosed with a learning disability or been enrolled in special education classes?

Yes
No

Have you ever been diagnosed with an attention deficit?

Yes
No

Have you ever been treated for or thought you might need treatment for an alcohol or drug addiction?

Yes
No

Have you ever had metal fragments in the eye, or are you a metal worker?

Yes
No

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.)?

Yes
No

Do you require vision correction?

Yes
No