Basic Screening
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Email address (it will be used to contact you so please verify it is correct!)
OR Anonymous ID (If you wish to send this form anonymously, please fill in an anonymous ID of your choice then send an email with this anonymous ID)
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Age *
Gender *
Are you a native English speaker or bilingual (raised in an English speaking environment from youth)?
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If you are bilingual in English, please tell what is your primary language, and describe shortly your learning environment for English
Are you right-handed?
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Please indicate which hand you prefer to use when:
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Left
No pref
Right
Writing
Drawing
Throwing
Using scissors
Using a toothbrush
Using a knife (without a fork)
Using a spoon
Using a broom (upper hand)
Striking a match
Opening a box (lid)
Do you currently take medications that have an influence on your central nervous system ? (e.g., anxiolytics, antidepressants, antipsychotics, antiepilectics, sleeping medication, ADHD treatment, etc.)
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Do you suffer from any major neurological or psychiatric disorder? *
Do you suffer from any cognitive impairment? *
If yes to one of these three questions, please specify
Do you suffer from any hearing impairment/loss? *
Did you had a middle ear infection as a child? *
Do you have any hearing impairment or Tinnitus? *
Do you use any hearing aids? *
Do you know of any other condition you have which might affect your ability to perceive or produce speech? *
Do you know of any other condition you have which might affect your ability to perceive or produce music? *
 If yes to one of these two questions, please specify
Do you have to wear prescription glasses or contact lenses? *
Do you suffer from any other visual impairment/loss? (e.g. oculomotor disorders) *
Do you know of any other condition you have which might affect your ability to read words? (e.g. dyslexia)
 *
Do you know of any other condition you have which might affect your ability to read music? (e.g. amusia)
 *
 If yes to one of these three questions, please specify
Do you have any experience as a musician ?
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If yes, please provide some details (years of experience, instrument played)
Do you have any PROFESSIONAL experience as a musician ?
 *
If not, are you currently studying in the field of music?
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How would you rate your ability to read music?
I can't read music
I read music very well
Clear selection
Did or do you have a class/formation focused on music reading? *
If yes, please indicate the type (e.g. sight-reading, accompaniment)
Did you have any major surgery? *
If yes, please indicate the type
Do you speak a tonal language fluently? *
Do you have a: *
Yes
No
Cardiac Pacemaker / Defibrillator
Cochlear implant or implanted hearing aid
Implanted insulin pump
Coloured contact lenses
Transdermal delivery system (e.g. patch )
Non removable body piercing
IUD
Foreign metallic objects (e.g. bullets or metal splinters)
Permanent make-up / tattoos
Ocular implants or devices
Cardiac valve prosthesis
Neurostimulator
Artificial limb or joint
Implanted orthopedic device
Penile implant
Aneurysm Clip
Filter, catheter or stent in a blood vessel
Shunt (programmable)
Braces, Dentures, Permanent Retainer or Partial Plates
Do you have any non-removable metallic object on your head or face (e.g., piercings, teeth retainers...)
 *
If you have non-removable metallic objects, please provide details
Have you ever been injured by a metallic piece? (e.g. in your eyes) *
Do you suffer from claustrophobia? *
Are you pregnant? *
Have you ever undergone Magnetic Resonance Imaging? *
If there are no slots available for the current study, do you consent that we keep your information to contact you for other fMRI studies?
 *
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