NeuroNest Pre-Screening Questionnaire – Pilot Recruitment

  • NeuroNest Pre-Screening Questionnaire - Pilot Recruitment Study

    Title: Military NeuroNest Data Collection Study

  • Instructions: This online questionnnaire is designed to assess your eligibility for NeuroNest's research study at the Veteran Services Center at Goodwill.

  • To be eligible you need to: Be a veteran, Have a diagnosis of Post-Traumatic Stress Disorder (PTSD), Be between 18-65 years of age, Speak and understand English fluently. 

  • We will ask you to self-report your Veteran status, you 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.

  • Section 1: General Information

  • Format: (000) 000-0000.
  • Are you a military veteran?*
  • Do you speak English fluently?*
  • Do you understand English fluently?*
  • Have you previously been diagnosed with Post-Traumatic Stress Disorder (PTSD) by a healthcare provider?*
  • Have you experienced a traumatic event that continues to impact your daily life?*
  • Are you currently receiving treatment for PTSD?*
  • Are you currently taking any medications for PTSD or anxiety?*
  • Have you participated in relaxation or stress-reduction techniques before?*

  • 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 the stressful experience?*
  • Repeated, disturbing memories, thoughts, or images of the stressful experience?*
  • Repeated, disturbing dreams of the stressful experience?*
  • Repeated, disturbing dreams of the stressful experience?*
  • Suddenly feeling or acting as if the stressful experience were happening again (flashbacks)?*
  • Suddenly feeling or acting as if the stressful experience were happening again (flashbacks)?*
  • Feeling very upset when something reminded you of the stressful experience?*
  • Feeling very upset when something reminded you of the stressful experience?*
  • Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
  • Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
  • Avoiding memories, thoughts, or feelings related to the stressful experience?*
  • Avoiding memories, thoughts, or feelings related to the stressful experience?*
  • Avoiding external reminders of the stressful experience (for example: people, places, conversations, activities, objects, or situations)?*
  • Avoiding external reminders of the stressful experience (for example: people, places, conversations, activities, objects, or situations)?*
  • Trouble remembering important parts of the stressful experience?*
  • Trouble remembering important parts of the stressful experience?*
  • Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?*
  • Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?*
  • Blaming yourself or someone else for the stressful experience or what happened after it?*
  • Blaming yourself or someone else for the stressful experience or what happened after it?*
  • Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
  • Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
  • Loss of interest in activities that you used to enjoy?*
  • Loss of interest in activities that you used to enjoy?*
  • Feeling distant or cut off from other people?*
  • Feeling distant or cut off from other people?*
  • Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *
  • Trouble experiencing positive feelings (for example: being unable to feel happiness or have loving feelings for people close to you)?*
  • Trouble experiencing positive feelings (for example: being unable to feel happiness or have loving feelings for people close to you)?*
  • Irritable behavior, angry outburst, or acting aggressively?*
  • Irritable behavior, angry outburst, or acting aggressively?*
  • Taking too many risks or doing things that could cause you more harm?*
  • Taking too many risks or doing things that could cause you more harm?*
  • Being "superalert" or watchful or on guard?*
  • Being "superalert" or watchful or on guard? *
  • Being "superalert" or watchful or on guard?*
  • Feeling jumpy or easily startled?*
  • Feeling jumpy or easily startled? *
  • Having difficulty concentrating?*
  • Having difficulty concentrating?*
  • Trouble falling or staying asleep?*
  • Trouble falling or staying asleep?*

  • Section 3: Study Participation 

    NeuroNest is conducting an in-person research study at the Veteran Services Center at Goodwill. 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 the Veterans Services Center at Goodwill located at 1750 Monocacy Boulevard, Suite A, Frederick, MD 21701?*
  • 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.*
  • Which branch of the U.S. military did you serve in? (Select all that apply)*

  • 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!

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