Brain Imaging Study ITV- LONDON Wide – IN PERSON

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 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 have 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?

Do you suffer from severe sensitivity to light?
YesNo

Have you had any Brain Surgery or had any type of Brain Injury in the past?
YesNo

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

YesNo

What is your Marital Status?

SingleMarriedCo-habitingWidowedDivorcedSeparated

In order to comply with Government advice on COVID-19 procedures, we need to ask the following questions?
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 who is pregnantNone of these

Which of the following television stations do you watch regularly nowadays, by regularly I mean at least once a week?
BBC1BBC2ITV (Main Channel Not ITV2 etc)CHANNEL 4CHANNEL 5SKY

Which of these programmes do you watch nowadays?
EmmerdaleCoronation StreetWho Wants to Be a MillionaireClarkson on TVLoose WomenThis MorningThe VoidNone of these

Are there any programmes on this list that you consider watching in the future (ie. not reject watching?)
EmmerdaleCoronation StreetWho Wants to Be a MillionaireClarkson on TVLoose WomenThis MorningThe VoidNone of these

Are there any brands on this list that you dislike/would never use?
TescoVoltarolEBAYTalk TalkGilletteThe National LotteryFacebook

Which group are you interested in attending?
Friday 23rd July - 9:30amFriday 23rd July -11:00amFriday 23rd July - 1:00pmWednesday 28th July - 9.30amWednesday 28th July - 2:30 pmWednesday 28th July - 4:00pm