Form
NeuroNest Pre-Screening Questionnaire – Pilot RecruitmentStudy Title: Military NeuroNest Data Collection StudyInstructions: This online questionnaire is designed to assess your eligibility for NeuroNest’s research study at Premier Health Express. To be eligible you need to:Be a veteranHave a diagnosis of Post-Traumatic Stress Disorder (PTSD)Be between 18-65 years of ageSpeak and understand English fluently. We will ask you to self-report your Veteran status, your English fluency and your PTSD symptoms based on your experiences in the past month. Please read each statement carefully and select the response that best describes your situation. Your responses are confidential.If you are eligible to participate in this study, we will schedule a phone call with you for a second screening. If you are deemed eligible for the study, after the phone call, you will be invited to participate in the study.
Email
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example@example.com
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Are you a military veteran?
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Yes
No
What is your age? Must be between 18-65
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What is your height?
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What is your weight?
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Do you speak English fluently?
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Yes
No
Do you understand English fluently?
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Yes
No
Have you previously been diagnosed with Post-Traumatic Stress Disorder (PTSD) by a healthcare provider?
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Yes
No
Have you experienced a traumatic event that continues to impact your daily life?
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Yes
No
Are you currently receiving treatment for PTSD?
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Yes
No
Are you currently taking any medications for PTSD or anxiety?
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Yes
No
Have you participated in relaxation or stress-reduction techniques before?
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Yes
No
Section 2: PTSD Symptom Checklist (PCL-5) - DSM-5 Standardized Questions Instructions:
Indicate how much you have been bothered by the following problems in the past month.
Repeated, disturbing memories, thoughts, or images of a stressful experience?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Repeated, disturbing dreams of a stressful experience?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Suddenly feeling or acting as if a stressful experience were happening again (flashbacks)?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Feeling very upset when something reminded you of a stressful experience?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Avoiding thoughts or feelings related to a stressful experience?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Avoiding people, places, or activities that remind you of a stressful experience?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Trouble remembering important parts of a stressful experience?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Loss of interest in things you used to enjoy?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Feeling distant or cut off from others?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Feeling emotionally numb or unable to feel happiness or love?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Feeling irritable or having angry outbursts?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Taking more risks or engaging in reckless behavior?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Being constantly on guard or easily startled?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Having trouble concentrating?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Trouble falling or staying asleep?
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Not at all (0)
A little bit (1)
Moderately (2)
Quite a bit (3)
Extremely (4)
Section 3: Study Participation NeuroNest is conducting an in-person research study at Premier Health Express. The purpose of the study is to identify new ways of enhancing wellness among veterans with PTSD. Participation involves two visits that each last around 90 minutes.
Are you willing and able to participate in-person at Premier Health Express?9710 Patuxent Woods Drive, Suite 200, Columbia, MD, 21046*
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Yes
No
Are you willing to have biosensors applied to your skin on up to six different body areas (arms, legs, neck, upper back, ankles)? The biosensors will be placed by a professional and will be removed immediately if causing discomfort.
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Yes
No
Which branch of the U.S. military did you serve in? (Select all that apply)
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Army
Navy
Marine Corps
Air Force
Coast Guard
Space Force
National Guard
Thank you for your response! We will review your responses and contact you via email with an update. If you qualify, we will schedule a phone screening, during which we will ask questions similar to those in this online questionnaire. Confidentiality Notice: Your responses are confidential and will be used only for research purposes. If you have any concerns, please contact the research team.Thank you for your participation! Thank you. You are eligible for the study. Here’s what to expect: The study will take place at Premier Health Express. You will come in for two 90-minute sessions. In one, you will wear sticky sensors on your body while resting with the NeuroNest system. In the other, you’ll lay down quietly with the sensors—no needles, no invasive procedures. You will complete a short survey before and after, and everything you share is confidential and will not be shared with other institutions or agencies. Upon completion, you’ll receive a $50 Visa gift card for your time. You are free to withdraw from the study at any time for any reason. We also have mental health resources available if you ever need extra support.
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