Please enter today's date.
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Today M-D-Y
First Name
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Last Name
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How did you hear about this study?
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Craigslist Facebook Instagram Clinicaltrials.gov Research Match Friend Flyer Unsure TV YouTube Reddit MU Info Streaming Service Flyer (Mall) TrialFacts/Vital Research Twitter TikTok
Which TV channel did you see our advertisement on? (Leave blank if not sure.)
Date of Birth
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Today M-D-Y
Female Male Other Prefer not to say
Asian Black/ African American Declined Mixed/Multiple Native American Native Hawaiian/Pacific Islander Other White
Ethnicity
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Hispanic or Latino Non-Hispanic or Latino Does not wish to specify
Zip Code
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How many years of education do you have?
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Phone Number
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Email
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What is your preferred method of contact?
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Call Text Email
If you are ineligible for this particular study, would you like to be contacted for future research studies that you may be eligible for?
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Yes No
Do you currently smoke?
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Yes No
How many years have you smoked?
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About how many cigarettes do you smoke per day?
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What is your preferred brand of cigarettes?
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Do you prefer menthol or non-menthol cigarettes?
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Menthol
Non-menthol
Do you currently use any other nicotine or tobacco products daily?
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E-cigarette
Vaping
Dip
Cigars
Pipes
Other
None
Do you take any prescription medications?
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Yes No
Do you take anything over the counter on a daily basis?
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Yes No
Please list OTC medications
For females:
The study also requires that, if sexually active, you use two effective methods of contraception during the time you sign consent through the end of the study drug administration. Are you willing to do that?
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Yes No N/A Male
Are you currently using any smoking cessation medications such as Chantix, Zyban, Wellbutrin, or any nicotine replacement products such as the patch, gum, lozenge, nasal spray, or inhaler with the intent to quit smoking?
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Yes
No
If female, are you pregnant or nursing?
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Yes No N/A Male
Do you think you might be claustrophobic or afraid of small spaces?
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Yes No
Have you ever had a concussion?
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Yes No
Are you oversensitive to light, touch, or noise?
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Yes No
Do you have a cochlear implant or staples in your ears?
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Yes No
Do you have metal clips, pins, or plates in your head or brain?
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Yes No
Do you have any metal clips or pins anywhere else in your body?
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Yes No
Do you have any surgical mesh anywhere in your body?
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Yes No
Do you have any kind of surgical implant such as a nerve stimulator, heart pacemaker, stent, replacement valve, or infusion pump?
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Yes No
Do you currently wear braces?
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Yes No
Have you ever been exposed to metal being welded, drilled, or cut?
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Yes No
If yes, is there any possibility of metal or metal pieces in your eyes?
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Yes No N/A
If yes, have you ever been treated for metal in your eyes?
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Yes No N/A
Have you ever been shot?
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Yes No
If yes, is there a possibility that the bullet or bullet fragments are still inside your body?
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Yes No N/A
Do you have tattoos on your face, or permanent tattooed eyeliner or makeup?
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Yes No
Do you have a false eye?
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Yes No
If yes, is it magnetic?
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Yes No N/A
Do you have any body piercings you would not be willing or able to remove?
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Yes No
Have you ever been diagnosed with a neurological condition?
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Yes No
Have you ever been diagnosed with a mental health condition?
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Yes No
Do you currently have any untreated illnesses?
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Yes No
Are you sensitive or allergic to antibiotics?
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Yes No
Do you drink alcohol?
This information is not exclusionary and is just for characterization purposes. We appreciate your honesty.
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Yes No
If yes, what type of alcohol do you usually drink and how many drinks do you usually have?
Example: wine three times per week
Do you use recreational drugs?
This information is not exclusionary and is just for characterization purposes. We appreciate your honesty.
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Yes No
If yes, what recreational drugs do you use? How frequently do you use this substance?
Example: marijuana twice weekly
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