College Student Brain Study Eligibility Screen

1. What is your full name?

2. What is your email?

3. What is your phone number?

4. When is the best time of the day to call you?

5. Gender:

6.What is your date of birth?

7. Age:

7a. Is the age listed in the previous question correct? If no, please re-enter your day, month and birth year above.

8. Are you currently a student in program that is at least 4 years?

9. At which school?

10. When did you start this program?

11. Do you plan to be in this program continuously until you finish?

11a. Where do you currently live while attending this program?

11b. If other, please describe:

12. Are you right-handed or left-handed?

13. Please estimate your current weight.

14. Is english your native language?

15. If not, at what age did you become fluent in English?

16. If not originally from the U.S., how many years have you lived here?

17. When you were younger, did you ever have difficulties in school? For example trouble learning to read, or with certain subjects requiring special help/classes, or did you ever repeat a grade, have problems with attention, hyperactivity, attendance, fights or suspensions?

18. Please describe:

19. Have you ever had an MRI or other scan before now?

20. When?

21. For medical or research purposes?

22. What body part?

23. Was there any problem with completing the scan?

24. Could you have any metal in or on your body that cannot be removed?

25. Please describe:

26. Have you ever been exposed to an explosion or shrapnel, or been shot, or had an accident where you may have gotten metal in your eyes or body?

27. Please describe:

28. Was it removed?

29. When was it removed?

30. Have you ever worked with metal? e.g sheet metal or welding or automotive repair

31. Do you wear glasses or contacts?

32. Do you have any medical patches that can't be removed such as a birth control patch or hormone patch?

33. Have you missed any periods or had irregular periods in the past 6 months?

34. Do you usually have a regular menstrual cycle?

35. Have you used hormonal contraceptives within the past 6 months?

36. What type/brand?

37. Is the type of birth control pill you take triphasic?

38. Have you ever been pregnant?

39. How long ago was your most recent pregnancy?

40. Are you currently nursing/breastfeeding?

41. Do you currently drink alcohol?

41a. In your lifetime, did you ever drink?

i.e., In your lifetime, have you had at least two drinks?



Note: One drink is defined as 12 oz. beer, 5 oz. wine, 1.5 oz hard liquor, or the equivalent.

42. In your lifetime, have you had more than one occasion of "heavy drinking"?



Heavy drinking =

female: 4 or more drinks on one occasion

male: 5 or more drinks on one occasion



Note: One drink is defined as 12 oz. beer, 5 oz. wine, 1.5 oz hard liquor, or the equivalent.

42a. In the past 30 days, how many of these "heavy drinking" occasions have you had?

42b. In the past 3 months, how many of these "heavy drinking" occasions have you had?

42a. On average, how many days per month do you have at least one drink?

42b. On average, how many drinks do you have during an occasion of drinking?

42c. On average, how many drinks do you have in a month?

43. Was there ever a time period when you drank more than you do now?

43a. When was that?

43b. During this time period, on how many occasions per month did you have at least one drink?

43c. During this time period, what was the average number of drinks you had per occasion?

43d. During this time period, what was the highest total number of drinks you had in one month?

44. During the time period of your greatest alcohol use, did any of the following things happen? (check all that apply)

41. Do you currently drink alcohol?

42. Did you ever drink? (i.e., at least two standard drinks: 12 oz. beer, 5 oz. wine, 1.5 oz hard liquor, or the equivalent.)

45a. How old were you when you had your first full drink (not just sips)?

43. In your lifetime, have you had "heavy drinking" days?



Heavy drinking: female: 4+ drinks per drinking session male: 5+ drinks per drinking session



Note: One drink is defined as 12 oz. beer, 5 oz. wine, 1.5 oz hard liquor, or the equivalent.

44. In the past 30 days, how many of these "heavy drinking" days have you had?

45. In the past 3 months, how many of these "heavy drinking" days have you had?

46. In the past 6 months, how many of these "heavy drinking" days have you had?

47. On average, over the last six months, how often did you have at least one drink?

48. When you drink, how many drinks do you generally have on a given night?

49. How many days in total have you had a drink in the past month?

50. How many times have you had more than 2 drinks on one night in the past month?

51. What is the greatest number of drinks you've had on a single night in the past month?

52. On the night when you had the most drinks on a single night in the past month, how many hours from first drink until last?

53. In your lifetime, was there ever a time when you drank more than this?

54. During what years?

55. How often would you drink?

56. How much would you drink?

57. During this period of greatest use, did any of the following things happen? (check all that apply)

58. Did you ever smoke cigarettes regularly?

59. Have you smoked cigarettes on more than 25 occasions in your lifetime?

At what age did you first try smoking cigarettes?

At what ages were you smoking regularly?

How many cigarettes do you (or did you) smoke per day?

67. Have you ever used synthetic marijuana? (e.g. K2, spice)

68. On average, over the last three months, how often did you use marijuana?

69. Over the past three months, what is the total number of times you've used marijuana?

70. In your lifetime, was there ever a time when you used more marijuana than this?

71. When was that?

72. How often would you use marijuana?

73. About how many times have you used marijuana in your lifetime?

73. On average, over the last three months, how often did you use cocaine?

74. Over the past three months, what is the total number of times you've used cocaine?

75. In your lifetime, was there ever a time when you used more cocaine than this?

76. During what years?

77. How often would you use cocaine?

78. On average, over the last three months, how often did you use amphetamines?

79. Over the past three months, what is the total number of times you've used amphetamines?

80. In your lifetime, was there ever a time when you used more amphetamines than this?

81. During what years?

82. How often would you use amphetamines?

83. On average, over the last three months, how often did you use opiates?

84. Over the past three months, what is the total number of times you've used opiates?

85. In your lifetime, was there ever a time when you used more opiates than this?

86. During what years?

87. How often would you use opiates?

88. On average, over the last three months, how often did you use hallucinogens?

89. Over the past three months, what is the total number of times you've used hallucinogens?

90. In your lifetime, was there ever a time when you used more hallucinogens than this?

91. During what years?

92. How often would you use hallucinogens?

93. On average, over the last three months, how often did you use club drugs?

94. Over the past three months, what is the total number of times you've used club drugs?

95. In your lifetime, was there ever a time when you used more club drugs than this?

96. During what years?

97. How often would you use club drugs?

98. Which other drugs have you used?

99. On average, over the last three months, how often did you use other drugs?

100. Over the past three months, what is the total number of times you've used other drugs?

101. In your lifetime, was there ever a time when you used more other drugs than this?

102. During what years?

103. How often would you use other drugs?

104. Do you currently have any medical illnesses?

Please describe your medical illness:

105. Do you have any chronic medical conditions?

106. Please specify:

107. Have you ever had a serious illness such as a heart attack or pneumonia?

Please describe.

108. Have you ever had a nervous system problem (such as seizures or diabetes)?

Please describe.

109 Are you currently taking any medications?

110. Which medications are you taking?

111. Do you take vitamins or supplements on a regular basis?

112. Which vitamins or supplements do you take?

113. Have you ever had a long-term prescription? (For more than 2 weeks.)

114. What were the names of the long-term prescription(s)?

115. Have you ever been prescribed medication for a psychological problem, including ADHD (e.g. Ritalin or Adderall)?

116. What drug?

117. During what time period did you take this drug?

118. For what problem did you take this drug?

119. Have you ever had a head injury or concussion?

120. Have you ever lost consciousness, fainted, or passed out?

121. Why did you lose consciousness and how long was the loss of consciousness?

122. Have you ever been seen by a psychologist, psychiatrist, or counselor for any reason?

123. Were you diagnosed with any psychological disorder? Were you prescribed any medication? Please describe, including time frame.

Have you ever received treatment for your substance use or alcohol use?

Please describe the treatment

124. Have you ever experience a period of depression or sadness that lasted for longer than 2 weeks? (not including normal grief/bereavement)

125. Have you ever had a panic attack, when for no apparent reason you suddenly feel panic, fear or extreme anxiety, or physical symptoms such as a racing heart, shortness of breath, and sweating?

126. How often has this occurred?

127. Do you get extremely uncomfortable or afraid when you are in a small, cramped space?

128. Do you have other specific fears?

129. Please Describe:

130. To your knowledge, have any of your direct family (grandparents, parents, siblings, children) ever had either a psychiatric illness or learning disability?

131. Please specify which relative and what their diagnosis is:

Our lab and other labs at McLean are often recruiting for other studies. Would you be interested in our keeping your information and notifying you if you might be eligible for additional studies?