The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

3YnrATquoEqCzQJSPEV3kGQJRm6AcYxJSQEvagiGPIBZi2kq3RHHdovm56rG4yTqJPJ8TB5IFobU2dg9j4qFyVr4eu3VSQxrdVXG9Rr8DmaJ34B

Stress Study Screening Survey

Thank you for your interest in our research.

Please complete the survey below to help us determine whether you might be a good fit for our study. After you complete the survey, if it looks like you may be eligible for a current project, then we will call you to complete the screening process.

Record ID

First Name

Age

Height

Weight

Telephone Number

Is it ok for our lab to leave a detailed message if we reach your voice mail?

Yes

reset

Do we have permission to contact you via email?

Yes

reset

A quick note about emails and privacy: the Mass General Brigham standard is to send email securely. That requires you to set up and activate an account with a password. If you prefer, we can send you "unencrypted" email that is not secure. That could result in the unauthorized use or disclosure of your information. If you want to receive unencrypted emails despite those risks, Mass General Brigham won't be held responsible. Your preference to receive unencrypted email will apply only to emails sent from this research group. What's your preference: should we send emails securely (requiring a password), or non-securely?

Securely

Non-securely

reset

Gender

What language was spoken at home when you were growing up?

What language was spoken at school when you were a child?

What country did you grow up in?

Are you fluent in written and spoken English?

Yes

reset

What hand do you use for writing?

Right

Left

Both

reset

Are you currently taking any prescription medications?

Yes

reset

Please type the names of the medications that you are taking

Expand

Please check any that apply:

Taking birth control pill

Have an IUD

Have other hormonal BC (Implanon, Depo shot, etc.)

Breastfeeding

Pregnant

Menopause

On other hormonal medication

None of the above ("naturally cycling")

Is it a copper IUD?

Yes

reset

Have you ever been diagnosed with a mental health problem?

Yes

reset

What type of mental health problem were you previously diagnosed with? Please check all that apply.

Anxiety

Bipolar Disorder

Depression

Eating Disorder (anorexia or bulimia)

Generalized Anxiety Disorder

Obsessive Compulsive Disorder

Panic Disorder

Posttraumatic Stress Disorder (PTSD)

Schizophrenia

Schizoaffective Disorder

Other

I'm not sure

Our lab runs studies that involve different types of activities. Please indicate whether you would be willing to do the following types of activities.

* must provide value

Clinical interview

MRI scanning

Blood draw

Do you have any of the following items in or on your body?

Braces on your teeth

Permanent retainer glued to teeth

IUD

Surgical hardware (pins, rods, screws, plates)

Implanted device (pacemaker, defibrillator, neurostimulator)

*** Our lab has a number of ongoing projects, and new projects are also being developed.

Do we have your permission to keep your information and contact you in the future if we have a different project that you might qualify for?

Yes

reset

Yes

Not Sure

Being raped or sexually assaulted

reset

Being in a severe car accident

reset

Being physically attacked (punched, hit, kicked, bitten)

reset

Being physically abused as a kid

reset

Being sexually abused as a kid

reset

Seeing someone else get badly hurt or killed

reset

Finding out that someone close to you was murdered, raped, assaulted, or killed in an accident

reset

Being in a serious accident at work, home, or while playing sports

reset

Seeing a serious accident

reset

Being robbed, mugged, or held at gunpoint

reset

You had an acute (sudden) life-threatening medical crisis

reset

Witnessing a loved one having an acute (sudden) life-threatening medical crisis

reset

Someone threatened to rape or sexually assault you

reset

Seeing/hearing someone get physically or sexually abused

reset

Someone threatened to hurt or kill you with a weapon

reset

Learning that someone close to you committed suicide

reset

Directly (personally) experiencing a terrorist attack

reset

Being in a natural disaster that threatened your life

reset

Being in a serious fire, explosion, or industrial accident

reset

Being in a severe boat, train, or plane crash

reset

Being exposed to extremely upsetting content as part of work (like forensic work)

reset

Exposure to war/combat as a civilian

reset

Exposure to war/combat as military personnel

reset

Being kidnapped or taken hostage

reset

Being tortured

reset

Incarceration as a prisoner of war

reset

I have never been exposed to any of these events

reset

Not applicable (no history of intense events)

Not at all

A little bit

Moderately

Quite a bit

Extremely

1. Repeated, disturbing, and unwanted memories of the stressful experience?

reset

2. Repeated, disturbing dreams of the stressful experience?

reset

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

reset

4. Feeling very upset when something reminded you of the stressful experience?

reset

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

reset

6. Avoiding memories, thoughts, or feelings related to the stressful experience?

reset

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

reset

8. Trouble remembering important parts of the stressful experience?

reset

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

reset

10. Blaming yourself or someone else for the stressful experience or what happened after it?

reset

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

reset

12. Loss of interest in activities that you used to enjoy?

reset

13. Feeling distant or cut off from other people?

reset

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

reset

15. Irritable behavior, angry outbursts, or acting aggressively?

reset

16. Taking too many risks or doing things that could cause you harm?

reset

17. Being "superalert" or watchful or on guard?

reset

18. Feeling jumpy or easily startled?

reset

19. Having difficulty concentrating?

reset

20. Trouble falling or staying asleep?

reset

To confirm: in your LIFETIME, have you ever experienced a very intense, stressful, frightening, or potentially traumatic event?

Yes

reset

Sometimes people have memories of an intense experience that pop into their head unexpectedly (when
they're not trying to think about it). Do you sometimes have unexpected memories of that experience?

Yes

reset

When that memory pops up unexpectedly, how do you experience it? Does it involve (check all that apply):

Feelings/emotions

Sensory experiences (seeing, hearing, smelling, tasting, or touch sensations of the original experience)

Thoughts

Bodily sensations (e.g. heart pounds, hyperventilating, sweating)

How often does this memory pop into your mind unexpectedly (when you're not trying to think about it?)

Once per month

Once per week

More than once per week

Once per day

More than once per day

reset

Occasionally, people completing these surveys may need immediate help. This research lab does not handle mental health emergencies. If you have having thoughts of hurting or killing yourself, please call 911 or proceed to your local emergency room. If you need crisis management resources or help locating a therapist, here is a list of community resources that may be helpful.

Attachment:Resources.pdf

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.