Project BRAIN IMAGING – UK 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 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

During the session, you will be asked to take a ‘selfie’ and post it on Twitter alongside a hashtag (for this study). You do not need to be a Twitter user as we will provide mobile phones and accounts for this.

Please be assured your photo will be deleted at the end of the research group.

Are you happy to take a ‘selfie’ and load it onto our study hashtag?
YesNo

Which group are you interested in attending?
Wednesday 8th July - 1:00pmThursday 8th July - 1:00pm