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Required format:

XtgAzWXidU9kxUADP4fbmfUso6RUyePftQ4cSDdEUiQQXrRtTLGag

Health Neuroscience Center Screening Questionnaire

The Health Neuroscience Center at The University of Missouri is conducting research studies about smoking behavior and smoking cessation. Please complete this survey if you are interested in participating in any of these research studies.

Please enter today's date.

* must provide value

M-D-Y

First Name

* must provide value

Last Name

* must provide value

How did you hear about this study?

* must provide value

Which TV channel did you see our advertisement on? (Leave blank if not sure.)

Date of Birth

* must provide value

M-D-Y

Sex

* must provide value

Please Describe

Race

* must provide value

Ethnicity

* must provide value

Zip Code

* must provide value

How many years of education do you have?

* must provide value

Phone Number

* must provide value

What is your preferred method of contact?

* must provide value

If you are ineligible for this particular study, would you like to be contacted for future research studies that you may be eligible for?

* must provide value

Yes No

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Do you currently smoke?

* must provide value

Yes No

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How many years have you smoked?

* must provide value

About how many cigarettes do you smoke per day?

* must provide value

What is your preferred brand of cigarettes?

* must provide value

Do you prefer menthol or non-menthol cigarettes?

* must provide value

Menthol

Non-menthol

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Do you currently use any other nicotine or tobacco products daily?

* must provide value

E-cigarette

Vaping

Dip

Cigars

Pipes

Other

None

Do you take any prescription medications?

* must provide value

Yes No

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Please List Medications

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Do you take anything over the counter on a daily basis?

* must provide value

Yes No

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Please list OTC medications

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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?

* must provide value

Yes No N/A Male

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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?

* must provide value

Yes

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If female, are you pregnant or nursing?

* must provide value

Yes No N/A Male

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Do you think you might be claustrophobic or afraid of small spaces?

* must provide value

Yes No

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Have you ever had a concussion?

* must provide value

Yes No

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Are you oversensitive to light, touch, or noise?

* must provide value

Yes No

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Do you have a cochlear implant or staples in your ears?

* must provide value

Yes No

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Do you have metal clips, pins, or plates in your head or brain?

* must provide value

Yes No

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Do you have any metal clips or pins anywhere else in your body?

* must provide value

Yes No

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Do you have any surgical mesh anywhere in your body?

* must provide value

Yes No

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Do you have any kind of surgical implant such as a nerve stimulator, heart pacemaker, stent, replacement valve, or infusion pump?

* must provide value

Yes No

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Do you currently wear braces?

* must provide value

Yes No

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Have you ever been exposed to metal being welded, drilled, or cut?

* must provide value

Yes No

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If yes, is there any possibility of metal or metal pieces in your eyes?

* must provide value

Yes No N/A

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If yes, have you ever been treated for metal in your eyes?

* must provide value

Yes No N/A

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Have you ever been shot?

* must provide value

Yes No

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If yes, is there a possibility that the bullet or bullet fragments are still inside your body?

* must provide value

Yes No N/A

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Do you have tattoos on your face, or permanent tattooed eyeliner or makeup?

* must provide value

Yes No

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Do you have a false eye?

* must provide value

Yes No

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If yes, is it magnetic?

* must provide value

Yes No N/A

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Do you have any body piercings you would not be willing or able to remove?

* must provide value

Yes No

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Have you ever been diagnosed with a neurological condition?

* must provide value

Yes No

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If yes, please describe

Have you ever been diagnosed with a mental health condition?

* must provide value

Yes No

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If yes, please describe

Do you currently have any untreated illnesses?

* must provide value

Yes No

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If yes, please describe

Are you sensitive or allergic to antibiotics?

* must provide value

Yes No

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Do you drink alcohol?

This information is not exclusionary and is just for characterization purposes. We appreciate your honesty.

* must provide value

Yes No

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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.

* must provide value

Yes No

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If yes, what recreational drugs do you use? How frequently do you use this substance?

Example: marijuana twice weekly

Notes:

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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.