Study Participation Questionnaire

This form is used to gather information about individuals who may be interested in participating in a research study being conducted by Life University's Center for Chiropractic Research (CCR). All responses are protected and stored on a HIPPA compliant server. Please complete all items. Thank you.

Studies Contacted About

Applied Clinical Neuroscience and depression Global Mechanical Assessment Chiropractic care and recovery post stroke- Harris Perceived stress, EEG, HRV, and chiropractic- Bliese Force vs touch with a chiropractic adjustment Evaluation of movement symmetry Stress and HRV- Voelker

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Email *

example@example.com

What is your birthdate? *

Date

The next three questions provide some information that are important for studies that investigate interactions with our physiology.

I am a *

Biological Male Biological Female Other Prefer not to answer

Please choose all that may apply to you *

I consider myself in good health Hypertension Depression Diabetes PTSD Stroke None of these

Please select any/all medications or supplements that you are currently taking. *

Benzodiazapine (example:Xanax, Valium, Klonopin, Ativan) Narcotics (example: Percocet, Oxycodone, Hydrocodone, Fentanyl) NSAIDS (example: Aspirin, Ibuprofin, Diflusinal, Celebrex) Birth Control Steroids I'm not sure, but I do take at least one medication Vitamins and Supplements I do not take medications, supplements, or vitamins

Is there a specific study you would like to participate in? *

Applied Clinical Neuroscience and depression Global Mechanical Assessment Chiropractic care and recovery post stroke Perceived stress, EEG, HRV, and chiropractic Force vs touch with a chiropractic adjustment Evaluation of movement symmetry Any of these. They all sound interesting! None of these sound very interesting.

Would you like to be contacted about participating in future studies? *

Yes No

How did you hear about the Center for Chiropractic Research (CCR)? *

CCR recruitment (table, previous participation in a CCR study, campus event) Posted flyer Support Group Email Announcement Word of Mouth Social Media or CCR Website Participated in a CCR research study