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). Please complete all items. Thank you.

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 Perceived Stress and Autonomic Function Chiropractic and Stroke 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