Project BANKING (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

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?

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, hairpiece or any other head coverings or anything that will make access to your scalp difficult?

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 ResearchMarketingManagement ConsultingPublic RelationsFinance/BankingNone of the above

What is your Marital Status?

SingleMarriedCo-habitingWidowedDivorcedSeparated

What is your working status:

Full timePart timeNon workingRetired

WORKING FAMILIES

Which of the following best describes your current living arrangement?

Single person living aloneSingle person in shared accommodationLiving as a couple with no children in shared accommodation and sharing rooms with others (e.g. kitchen, living area, bathrooms)Living as a couple with no childrenParent/Guardian with children at home aged up to 24 yearsParent with children at home all aged 24 or overParent whose children have left homeNone of the above

How old are your children?
Please select all that apply

0-5 years old6-7 years old8-10 years old11-15 years old16-20 years old21-24 years old

MONEY BALANCERS

Which of the following best describes your personal/household finances month-to-month?

I have a good amount of money left over at the end of the monthI am fairly comfortable at the end of the monthI just about manage to make it to the end of the month without going into debtI struggle to make it to the end of the month and often go into debtI am always in debt by the end of the monthPrefer not to say

VARIABLE INCOME

And thinking about the money you have coming in each month, Would you say that…

Every month is the sameApart from occasional exceptional payments such as bonus etc. it is usually the same every monthMy income varies slightly month on monthEach month is different, and my income varies widelyPrefer not to say

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?

Group 5: Wednesday 16th December - 2:30pmGroup 6: Wednesday 16th December - 3:45pmGroup 7: Wednesday 16th December - 5:00pmGroup 8: Wednesday 16th December - 6:15pmGroup 13: Thursday 17th December - 1:15pm