Brain Imaging – Beer

First Name

Last Name

E-mail Address

Age

Date of Birth

Gender

Ethnicity

Occupation

Address

Post Code

Contact Number

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 RelationsSupermarketGrocery Store/Convenience StoreDrinks & Beverages (alcoholic/soft drinks)Retail/Manufacture/DistributionRestaurant, bar, serving drinksNone 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...

EpilepsyMigraineNeither

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

Which of the following best describes your current living situation?

Living with parents/under supervisionLiving in hall of residence or similarLiving with roommates in a flat or houseLiving alone in a flat or houseLiving with partner in flat or house

What is your Relationship Status?

Single, not seeing anyoneSingle, but datingIn a relationshipEngagedMarriedDivorced

What is your family status?

No childrenExpecting childrenHave children

Which of the following best describes your current employment status?

Work full time (more than 30 hours a week)Work part-time (less than 30 hours a week)Full-time studentStay At Home ParentCurrently unemployedRetired

How would you describe your current job and title?

What is the highest level of education you have completed?

School onlySchool training for a tradeSome college or universityCollege or university graduateSome post graduate schoolCompleted post graduate

Do you ever drink any of the following types of alcoholic drinks?

1) REGULARLY – at least once every week

BeerCiderWineChampagneMixed drinks (eg. vodka cranberry, rum & coke, vodka Red Bull)Any spirits such as vodka, rum, tequila, whiskey, – either alone with ice or straightCocktailsReady to drink alcoholic drinks / Premixed cocktails (eg. Smirnoff Ice, Bacardi Breezer)

2) OCCASIONALLY – for specific occasions, or without regularity

BeerCiderWineChampagneMixed drinks (eg. vodka cranberry, rum & coke, vodka Red Bull)Any spirits such as vodka, rum, tequila, whiskey, – either alone with ice or straightCocktailsReady to drink alcoholic drinks / Premixed cocktails (eg. Smirnoff Ice, Bacardi Breezer)

3) I NEVER have this

BeerCiderWineChampagneMixed drinks (eg. vodka cranberry, rum & coke, vodka Red Bull)Any spirits such as vodka, rum, tequila, whiskey, – either alone with ice or straightCocktailsReady to drink alcoholic drinks / Premixed cocktails (eg. Smirnoff Ice, Bacardi Breezer)

Generally speaking, who is responsible for purchasing the beer that you drink?

I am solely responsible for purchasing the beer I drinkI usually purchase the beer myself but sometimes others purchase it for meI occasionally purchase the beer myself but typically others purchase the beer I drinkI rarely purchase the beer I drinkI never purchase the beer I drink, I always rely on others

What beer brands do you tend to drink REGULARLY (at least three times within a month)?

FostersBudweiserCarlsbergCarlingRed StripeSkolCoors LightSan Miguel*Stella Artois*Heineken*Corona*Becks*Kronenbourg*Becks*Peroni*Guinness*Asahi*

What about brands that you HAVE DRUNK but do not currently drink?

FostersBudweiserCarlsbergCarlingRed StripeSkolCoors LightSan Miguel*Stella Artois*Heineken*Corona*Becks*Kronenbourg*Becks*Peroni*Guinness*Asahi*

And which of the following brands of beer would you NEVER CONSIDER drinking in the future?

FostersBudweiserCarlsbergCarlingRed StripeSkolCoors LightSan Miguel*Stella Artois*Heineken*Corona*Becks*Kronenbourg*Becks*Peroni*Guinness*Asahi*

Which group are you interested in attending?

GROUP 7 - Sunday 6.15pmGROUP 9 - Monday 5.00pmGROUP 11 - Monday 7.30pm