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Subject Prescreening Form

If you are interested in getting involved with our research by participating in one of our studies, please complete our screening form to find out which studies you are qualify to participate in. Do not forget to submit the form, so we know what studies you are interested in.

After answering the first 9 introductory questions:

If you are interested in participating in an fMRI study please continue with the fMRI Screening section, question # 1, below and complete the full questionnaire.
If you are interested in any other type of studies, you are right handed, and you are available to come to our campus during the weekdays go to question #15 below and finish the form. If not, thank you for your interest but at this time we do not have any studies for you to participate in.
Questions and concerns can be emailed to scngroup@columbia.edu

Your Name:
Date:
Phone Number:
Email:
Preferred form of Contact:
Best time to contact:
Types of studies you'd like to participate in (Select at least one: hold down Shift (Mac) or Ctrl (PC) key to select more than one study)
Can you come to Columbia's Morningside Campus during the weekday?	Yes No
Which hand do you write with?
fMRI Screening Entering the MRI Suite will bring you to a region of a very strong magnetic field. Therefore, we need you to answer a few questions to determine whether it is safe and appropriate for you to participate in this study. Do you have any of the following implants or items within your body as a result of any prior or recent medical experience?
1) Cardiac pacemaker or Pacemaker Wires:	Yes No
2) Surgical Clips:	Yes No
a) Aneurysm clips:	Yes No
b) Intracranial bypass graft clips:	Yes No
c) Coronary artery bypass clips:	Yes No
d) Renal Transplant clips:	Yes No
e) Other vascular clips or filters:	Yes No
3) Surgical Staples or Wire Sutures:	Yes No
4) Any of the following Prosthesis:	Yes No
a) Middle ear prosthesis:	Yes No
b) Orbital (eye) prosthesis:	Yes No
c) Cardiac Valve:	Yes No
d) Artificial limb or joint prosthesis:	Yes No
e) Surgical screws, nails or rods:	Yes No
f) Breast Tissue Expander:	Yes No
5) Neurostimulator:	Yes No
6) Biostimulator:	Yes No
7) Shrapnel/bullets:	Yes No
8) Hearing Aids:	Yes No
9) IUD (for women only):	Yes No
10) Other Implants - Specify:
11) Have you ever worked as a welder or machinist?	Yes No
12) Have you ever had metal removed from your eyes?	Yes No
13) Are you currently using a nicotine patch?	Yes No
14) Do you have any metal of any kind in your body?	Yes No
If so, is it removable for the time period you are in the scanner?	Yes No
General Screening Please answer Yes or No to the following questions:
15) Do you have a current presence of pain anywhere or Chronic pain syndromes?	Yes No
16) Do you have a current or past history of primary psychiatric disorder?	Yes No
17) A current or past history of psychoactive substance abuse or dependence?	Yes No
18) Have you ever been diagnoses with any of the following:
a) Dementias	Yes No
b) Movement disorders (except familial tremor)	Yes No
c) Any diseases/irregularities of the Central Nervous System (CNS)	Yes No
d) Inflammatory or autoimmune disease	Yes No
e) Seizure disorder	Yes No
f) History of closed head trauma with loss of consciousness	Yes No
g) Current or past history of cancer or tumors	Yes No
i) Neuroendocrine disorders (e.g. Cushing’s disease) or Uncorrected hypothyroidism or hyperthyroidism	Yes No
j) Uncontrolled hypertension or hypotension :	Yes No
k) An abnormal MRI	Yes No
l) Chronic fatigue syndromes	Yes No
m) Claustrophobia	Yes No
19) Have you had prior or current treatment with any of the following:
a) Antidepressants	Yes No
b) Antipsychotics	Yes No
c) Mood stabilizers	Yes No
d) Isoniazid	Yes No
e) Glucocorticoids	Yes No
f) Opiates	Yes No
g) Centrally active antihypertensive drugs (e.g. clonidine, reserpine)	Yes No

Thank you for completing our screening form. When you hit submit button, the information will be sent securely to our subject coordinator. We will contact you in the next couple of weeks with scheduling information based on your responses. If you answered yes to any of questions 1 to 14 it would not be safe for you to enter the MRI area. Therefore you would not qualify for that type of study, but we will notify you of our other studies available. Thank you for your interest!