Mum / Baby Skincare – London only (Brain Imaging)

First Name

Last Name

E-mail Address

Age

Date of Birth

Gender

Ethnic Origin

Occupation Of Head Of Household

Occupation Of Respondent

Address

Post Code

Contact Number

Have you taken part in any Brain Imaging research before?

YesNo

Do you suffer from any of these conditions?
Cardiovascular DiseaseCancerDiabetesChronic Respiratory DiseaseChronic Kidney DiseaseLiver DiseaseMorbid ObesityBrain or Nervous System DisorderNone Of These

Are you:
Taking ImmunosuppressantsPregnant or do you live with someone pregnantnone of these

Do you or any members of your household currently work, or have ever worked in any of the following industries/occupations?

Advertising agency or advertising department within a companyMedia/Journalism/PublishingMarket ResearchMarketingPublic RelationsNone of the above

Are you a permanent resident in the UK and been living in the UK for the last year?

Yes, I am a permanent UK resident and have lived in the UK for the last yearNo, I am not a permanent UK residentI am a UK resident but I have not lived in the UK for at least one year

Do you suffer from...

EpilepsyMigrainesNeither

How often do you suffer from migraines?

Once or twice a weekOnce a monthLess than once a monthNever

What triggers your migraines?

This study requires access to your scalp - do you wear wigs, hairpiece or any other head coverings or anything that will make access to your scalp difficult?

YesNo

What is your Marital Status?

SingleMarriedCo-habitingWidowedDivorcedSeparated

Which of the following online sites has shopped from in the last 6 months?
AmazonSuperdrugTescoBootsOcadoSainsburyHolland & BarrettMorrisonsAsda

Have you visited the Tesco supermarkets website before?

No, I have never heard of itNo, but I have heard of itYes, only onceYes, a few times in the past

Have you visited the Boots health and pharmacy website before?
No, I have never heard of itNo, but I have heard of itYes, only onceYes, a few times in the past

Have you visited the Ocado online supermarket website before?
No, I have never heard of itNo, but I have heard of itYes, only onceYes, a few times in the past

Which of the following baby skin care brands do you usually purchase?
Aveeno BabyJohnsons BabyOilatumChild FarmBaby DoveWeledaSudocremOrganic BabiesOtherI don’t buy baby skincare products

Which of the following skincare brands do you usually purchase for yourself?
AveenoNeutrogenaLorealNiveaSukinOlayNip & FabDr BotanicalsOtherI don’t buy skin care products for myself

Do you purchase any of the following Over the Counter (OTC) medicine brands, for yourself or your child?
BenylinCalpolSudafedClaritynNurofenVicksPiritonLemsipOtherI don’t buy any over the counter medication

Do you purchase any of the following oral care brands?

ColgateOral BListerineAquafreshSensodyneWakenDentylUltraDEXOtherI don’t buy oral care products

Do you have COVID-19 or have you come into contact with someone who has COVID-19 within the past month?
YesNo

Have you or anyone you have knowingly been in contact with within the past month, experienced one or more of the following symptoms? High temperature/fever, continuous cough, loss or change of taste or smell.
YesNo

Are you happy for your contact information to be held for 21 days following the government’s guidelines on coronavirus tracking? This will allow the NHS Track and Trace service to contact anyone who has come into contact with a respondent or employee who has tested positive for COVID-19.
YesNo

Which group are you interested in attending?
Sunday 13th December - 11:15amSunday 13th December - 1:00pmSunday 13th December - 2:45pm