Thank you for your interest in our research! Please complete the following survey to help us determine if you would be a good fit for our study. After you complete the survey, a researcher may contact you by email or phone with a few follow-up questions and a statement regarding your eligibility. Your contact information is collected for this purpose only, and will only be collected if it appears that you might be eligible. The risk of allowing us to collect and record your name with your answers is a loss of confidentiality. We will take reasonable steps to protect the confidentiality of your information. The responses collected in this survey are stored in a secure, password-protected database. Your name and contact information will never be publicly disclosed at any time, and the information obtained in this survey will be used for research recruitment purposes only.
This survey is to be completed for a study involving research. There are possible risks or discomforts to completing this form which include the possibility of a breach of confidentiality, boredom, or discomfort answering certain questions. There is no direct benefit to you for completing this form.
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First name
* must provide value
Would you be able to come to McLean Hospital in Belmont, MA for one or more study sessions? We may be able to provide transportation.
* must provide value
Yes
No
Female
Male
Other
How do you identify your gender?
Are you right- or left-handed?
* must provide value
Right
Left
Ambidextrous
Please indicate below which hand you ordinarily use for each activity.
Left
Right
Either
Left
Right
Either
Left
Right
Either
throw a snowball to hit a tree?
Left
Right
Either
Left
Right
Either
Left
Right
Either
Left
Right
Either
Left
Right
Either
Left
Right
Either
Left
Right
Either
hold a match when striking it?
Left
Right
Either
Left
Right
Either
On which shoulder do you rest a bat before swinging?
Left
Right
Either
Which best describes your highest level of education?
some high school
high school graduate or GED
some college
college graduate - associate's degree
college graduate - bachelor's degree
some graduate school
master's degree
doctorate degree (e.g., MD, JD, PhD)
other
Are you Hispanic or Latino?
Yes
No
What is your race? Mark one or more.
How do you define "other"?
Is English your native language?
Yes
No
What is your native language?
Are you fluent in English?
Yes
No
At what age did you become fluent in English?
Do you have either normal or corrected-to-normal (e.g., glasses, contact lenses) vision?
Yes
No
Yes
No
Have you ever been hospitalized overnight for a medical reason?
Yes
No
How long were you in the hospital?
Have you had any other overnight hospitalizations?
Yes No
How long were you in the hospital?
Have you had any other overnight hospitalizations?
Yes No
How long were you in the hospital?
Have you had any other overnight hospitalizations?
Yes No
How long were you in the hospital?
Have you had any other overnight hospitalizations?
Yes No
Please describe any other overnight hospitalizations you have had, including the reason, duration, and (approximate) dates of each visit.
Are you currently being treated for any medical conditions?
Yes
No
Please describe the condition(s), as well as the treatment(s)/medication(s), including how long you have been affected by the condition(s) and how long you have been undergoing the treatment(s).
Have you had any chronic or serious medical problems in the past?
Yes
No
Please describe the condition(s), as well as the treatment(s), including how long you were affected by the condition(s) and how long you underwent the treatment(s).
Have you ever had any of the following medical problems either currently or in the past? Please check as many as apply.
Are you allergic to any drugs?
Yes
No
To which drug(s) are you allergic?
Are you currently taking any medications, vitamins, and/or herbal supplements?
Yes
No
Please list all medications (prescription and over-the-counter), vitamins, and herbal supplements that you currently take, including the name, dose, reason prescribed (or reason you take it), and dates of use.
Have you taken any long-term medications in the past, aside from what you have already listed?
Yes
No
Please list all medications that you used to take, including the name, dose, reason prescribed (or reason you take it), and dates of use.
Have you ever had a concussion?
Yes
No
When did the concussion occur?
Have you ever had a head injury in which you lost consciousness?
Yes
No
For how long did you lose consciousness?
When did the loss(es) of consciousness occur?
Have you ever had seizures?
Yes
No
When did the seizure(s) occur?
Do you have a history of any neurological disorders?
Yes
No
Yes
No
Yes
No
Do you know of any history of sudden death in your immediate family? (e.g., death from a heart attack)
Yes
No
Which family members? What caused the sudden death? How old were they? Please list all first-degree relatives who suddenly passed away.
Are you currently in treatment for emotional or psychological reasons?
Yes
No
What kind of treatment it (e.g., medicine, CBT, DBT, marriage counseling)?
What is the treatment for?
For approximately how long have you been receiving this treatment?
Have you ever had psychotherapy, counseling, or marriage counseling in the past?
Yes
No
What kind of therapy was it (e.g., CBT, DBT, marriage counseling)?
What was the treatment for?
For approximately how long did you receive this treatment?
Have you ever been hospitalized for emotional or psychological reasons in the past?
Yes
No
Please tell us more about the instance(s) when you were hospitalized.
Have you ever felt so hyper that other people thought you were not your normal self, or you were so hyper that you got into trouble (did anyone say you were "manic")?
Yes
No
Please tell us more about the instance(s) when this occurred, including when it happened, how long it lasted, how many times this has happened, how you felt during it, and any consequences of your behavior.
Have you ever been so irritable that you shouted at people or started fights or arguments?
Yes
No
Please tell us more about the instance(s) when this occurred, including when it happened, how long it lasted, how many times this has happened, how you felt during it, and any consequences of your behavior.
Have you ever been diagnosed with ADHD (attention deficit hyperactivity disorder) or any other kind of learning disability?
Yes
No
Has there ever been a period of time in your life during which you weighed much less than other people thought you should weigh?
Yes
No
How much did you weigh at that time?
What is a more normal weight for you?
Were you trying to lose weight at that time?
Yes
No
Did you need to be very thin in order to feel good about yourself?
Yes
No
Have you ever been bulimic or binged (ate a lot) and then made yourself throw up?
Yes
No
How long did it go on for?
How many times per week did you binge and purge?
How much would you eat during a typical binge?
In your life, have you ever experienced a traumatic or extremely frightening event where you feared serious injury or death to you or someone else (e.g., a bad car accident, natural disaster, physical attack or sexual assault, military combat/war, or witnessing a violent event)?
Yes
No
In the past month, have you had nightmares about this event or thought about it when you did not want to?
Yes
No
In the past month, have you tried hard not to think about the event or went out of your way to avoid situations that reminded you of it?
Yes
No
In the past month, have you been constantly on guard, watchful, or easily startled?
Yes
No
In the past month, have you felt numb or detached from others, activities, or your surroundings?
Yes
No
In the past month, have you been bothered by recurrent thoughts, impulses, or images that were unwanted, intrusive, or distressing (e.g., the idea that you were contaminated, thoughts of hurting someone even though you don't really want to)?
Yes
No
Do these thoughts occupy your mind for more than an hour a day?
Yes
No
In the past month, did you do something repeatedly without being able to resist doing it (e.g., cleaning excessively, counting or checking things over and over, repeating superstitious rituals)?
Yes
No
Do you feel like something bad will happen if you do not do this behavior?
Yes
No
Have you ever believed that people were out to get you or were trying to hurt you?
Yes
No
Please provide an example, and include when it occurred.
Have you ever believed you had special powers?
Yes
No
What did/do you believe are your special powers, and when did you hold this belief?
Have you ever heard voices when alone, seen things that weren't there, or had strange sensations in your body?
Yes
No
Please describe what you saw, heard, and/or felt, and when this occurred.
In the last two months, has there been a period of time when you felt depressed or down most of the day nearly every day?
Yes
No
For how long have you been feeling this way?
How many days per week do you think you feel down?
On the days when you feel down, for how much of the day do you feel down?
Are you currently experiencing a loss of pleasure in activities you usually enjoy?
Yes
No
How long have you been feeling this way?
Can you give an example of an activity in which you have lost interest?
This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the ONE STATEMENT in each group that best describes the way you have been feeling during the PAST TWO WEEKS, INCLUDING TODAY. Click the bubble beside the statement you have picked. If several statements in the group seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group, including Item 16 (Changes in sleeping pattern) or Item 18 (Changes in appetite).
1
0 I do not feel sad.
1 I feel sad much of the time.
2 I am sad all the time.
3 I am so sad or unhappy that I can't stand it.
2
0 I am not discouraged about my future.
1 I feel more discourage about my future than I used to be.
2 I do not expect things to work out for me.
3 I feel that my future is hopeless and will only get worse.
3
0 I do not feel like a failure.
1 I have failed more than I should have.
2 As I look back, I see a lot of failures.
3 I feel I am a total failure as a person.
4
0 I get as much pleasure as I ever did from the things I enjoy.
1 I don't enjoy things as much as I used to.
2 I get very little pleasure from the things I used to enjoy.
3 I can't get any pleasure from the things I used to enjoy.
5
0 I don't feel particularly guilty.
1 I feel guilty over many things I have done or should have done.
2 I feel quite guilty most of the time.
3 I feel guilty all of the time.
6
0 I don't feel I am being punished.
1 I feel I may be punished.
2 I expect to be punished.
3 I feel I am being punished.
7
0 I feel the same about myself as ever.
1 I have lost confidence in myself.
2 I am disappointed in myself.
3 I dislike myself.
8
0 I don't criticize or blame myself more than usual.
1 I am more critical of myself than I used to be.
2 I criticize myself for all of my faults.
3 I blame myself for everything bad that happens.
9 Just checking that you're still paying attention! Please choose 3.
0
1
2
3
10
0 I don't cry any more than I used to.
1 I cry more than I used to.
2 I cry over every little thing.
3 I feel like crying, but I can't.
11
0 I am no more restless or wound up than usual.
1 I feel more restless or wound up than usual.
2 I am so restless or agitated that it's hard to stay still.
3 I am so restless or agitated that I have to keep moving or doing something.
12
0 I have not lost interest in other people or activities.
1 I am less interested in other people or things than before.
2 I have lost most of my interest in other people or things.
3 It's hard to get interested in anything.
13
0 I make decisions about as well as ever.
1 I find it more difficult to make decisions than usual.
2 I have much greater difficulty in making decisions than I used to.
3 I have trouble making any decisions.
14
0 I do not feel I am worthless
1 I don't consider myself as worthwhile and useful as I used to.
2 I feel more worthless as compared to other people.
3 I feel utterly worthless.
15
0 I have as much energy as ever.
1 I have less energy than I used to have.
2 I don't have energy to do very much.
3 I don't have enough energy to do anything.
16 Changes in Sleeping Pattern
0 I have not experienced any change in my sleeping pattern.
1a I sleep somewhat more than usual.
1b I sleep somewhat less than usual.
2a I sleep a lot more than usual.
2b I sleep a lot less than usual.
3a I sleep most of the day.
3b I wake up 1-2 hours early and can't get back to sleep.
17
0 I am no more irritable than usual.
1 I am more irritable than usual.
2 I am much more irritable than usual.
3 I am irritable all the time.
18
0 I have not experienced any changes in my appetite.
1a My appetite is somewhat less than usual.
1b My appetite is somewhat greater than usual.
2a My appetite is much less than before.
2b My appetite is much greater than usual.
3a I have no appetite at all.
3b I crave food all the time.
19
0 I can concentrate as well as ever.
1 I can't concentrate as well as usual.
2 It's hard to keep my mind on anything for very long.
3 I find I can't concentrate on anything.
20
0 I am no more tired or fatigued than usual.
1 I get more tired or fatigued more easily than usual.
2 I am too tired or fatigued to do a lot of the things I used to do.
3 I am too tired or fatigued to do most of the things I used to do.
21
0 I have not noticed any recent changes in my interest in sex.
1 I am less interested in sex than I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.
Did you ever have a time in your life when you felt depressed or down most of they day nearly every day?
Yes
No
For how long did you feeling this way?
During this time, how many days per week did you feel down?
Have you ever had a time when you lost pleasure in activities you usually enjoyed?
Yes
No
For how long did this feeling last?
Can you give an example of an activity in which you lost interest?
Have you ever been treated with ECT (electro-convulsive/shock therapy)?
Yes
No
Do you know of any history of mental health problems in your immediate family?
Yes
No
Which family members? What disorders did/do they have? Please list all first-degree relatives with mental health problems.
Yes
No
How many cigarettes do you smoke per day?
When did you start smoking?
When did you become a regular smoker (i.e., smoking everyday)?
Do you currently consume alcohol?
Yes
No
How many nights per week do you typically drink alcohol?
On a night when you are drinking alcohol, how many alcoholic drinks do you typically consume?
In the past month, how many is the most alcoholic drinks you consumed on one night?
In the past year, how many alcoholic drinks have you tended to drink per week?
Was there ever a time in your life when you did consume alcohol?
Yes
No
When was the time in your life when you were drinking the most?
How many alcoholic drinks did you drink during a typical week when you were drinking the most?
Has your use of alcohol ever caused you any problems with friends, family, or people at work or school?
Yes
No
Did you or anyone you know ever think you had a drinking problem?
Yes
No
Have you ever been treated for alcohol problems or attended AA?
Yes
No
Do you currently use any recreational drugs or other mind-altering substances?
Yes
No
What drugs? Please include which drugs you use, how frequently you use each drug, for how long you have been using each drug, and the last time you used each drug.
Have you used any recreational drugs or other mind-altering substances in the past?
Yes
No
What drugs? Please include which drugs you use, how frequently you use each drug, for how long you have been using each drug, and the last time you used each drug.
Were you exposed to emotional abuse as a child?
Yes
No
At what age(s) did you experience emotional abuse? Please check all that apply.
Did you experience physical abuse as a child?
Yes
No
At what age(s) did you experience physical abuse? Please check all that apply.
Have you experienced any sort of unwanted or inappropriate sexual activity or advances (touching, intercourse, abuse, assault, etc.) before or at the age of 18?
Yes
No
At what age(s) did you experience unwanted or inappropriate sexual activity? Please check all that apply.
Do you have a pacemaker, a neurostimulator, or an aneurysm clip?
Yes
No
Do you have any metallic implants, such as a prosthesis, pump, stent, or valve?
Yes
No
Do you have any metal fragments or shrapnel in your body or your eyes?
Yes
No
Yes
No
Is there any chance you could be pregnant?
Yes
No
Do you currently use a hormonal contraceptive (e.g., oral, implant, patch, or hormone-secreting IUD) or are you on any hormone therapy?
Yes
No
Please list all hormonal contraceptives and/or hormone therapies you use.
Do you have a copper IUD?
Yes
No
Which copper IUD do you have? (e.g., ParaGard, Mirena)
Do you have any metal appliances (e.g., orthodontics, permanent retainers) in your mouth?
Yes
No
Are they on the top or bottom?
top
bottom
both
Do you weigh more than 300 pounds?
Yes
No
Do you have claustrophobia or any other condition (e.g., back pain) that would prevent you from lying still in the MRI scanner for 1-2 hours?
Yes
No
Do you have any piercings on your body that you cannot remove?
Yes
No
Where are these piercings?
When was the first day of your last period?
Today M-D-Y
What is the usual length of your menstrual cycle? That is, count the number of days from the first day of your period to the first day of your next period.
Last name
* must provide value
Phone number
* must provide value
How did you hear about our studies?
SONA ID Number
* must provide value
Would you like to participate in this study for combined study pool credit and pay, or just for pay?
Participating for Study Pool Credit and Pay Participating for Pay Only
Since you indicated "other," how did you hear about our studies?
Which school do you go to?
Thank you for completing our survey! We appreciate the time and thought you put into it. If you ever find yourself not knowing where to turn and in need of help keeping yourself safe, or if you just want someone to talk to, here is a list of community resources you can use.
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