Volunteer Questionnaire
If you are interested in participating in our research studies, please complete the questionnaire below and we will contact you again if you fit the requirement for any of our studies. Thank you!
Name *
Contact No. (Home) *
Contact No. (Handphone) *
Birthday *
Please use the format as MM/DD/YYYY such as 02/02/1991
E-Mail Address *
Gender *
Ethnicity *
Highest Education Qualification attained *
1. Are you Right handed? *
2. Are you currently pregnant? *
3. Do you have any visual impairment? *
If you answered Yes to Q3, please specify (for astigmatism or myopia, please state the degree):
4. Do you have any language impairment? *
If you answered Yes to Q4, please specify:
5. First Language *
6. Second Language (if any)
Clear selection
7. Do you have any metallic implants? *
If you answered Yes or Maybe to Q7, please specify:
8. Do you have any history of neurological or psychiatric disorders? *
If you answered Yes to Q8, please specify:
9. Do you have any chronic medical illnesses? *
If you answered Yes to Q9, please specify:
10. Are you on any long term medication? *
If you answered Yes to Q10, please specify:
11. Are you a smoker? *
12. Do you consume alcohol? *
If you answered Yes to Q12, please specify the amount and frequency:
13. Does being in a confined space discomfort you greatly? *
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