Today's date:
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Today M-D-Y
DESCRIPTION:
You are invited to participate in a screening survey to see if you meet criteria for taking part in our research study of how drugs of abuse influence the function of brain networks in humans. You will be asked to answer a few questions that will help us to determine if you are able to participate in the study we are currently conducting. After which point, if you are eligible, we will contact you with more information about the study and schedule you for an in-person visit here at Stanford University.
CONTACT INFORMATION:
If you have any questions, concerns, or complaints about this screening, contact Dr. Leanne Williams - 650.723.3579. If you want to talk to someone separate from the research team about a concern or complaint or your rights as a possible research subject, please contact the Stanford Institutional Review Board (IRB) to speak to an informed person who is separate from the research team, at 650-723-5244 (for medical studies), 650-723-2480 (for non-medical studies), or toll-free at 1-866-680-2906.
TIME INVOLVEMENT:
Your participation will take approximately 10-15 minutes.
RISKS AND BENEFITS:
The risks associated with this survey are minimal and you may choose not to answer any of the questions asked. There are no benefits from taking this survey, other than the possibility of participating in the research study, if you are eligible.
PAYMENTS:
You will not receive payment for taking part in this survey.
PARTICIPANT'S RIGHTS:
If you have read this form and have decided to participate in this survey, please understand your participation is voluntary and you have the right to discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled. The alternative is not to participate. You have the right to refuse to answer particular questions. Information you provide will be kept as confidential as possible as required by law. It is possible that the Food and Drug Administration, and other federal and state authorities, may inspect this record.
Do you consent to filling out this survey?
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Yes
No
Please write your signature by clicking the "Add signature" button (to the right) to indicate that you consent to filling out this survey.
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What is your full name?
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If you have a preferred name (different from your legal name), please write your preferred name here (if not, leave blank).
How do you describe your gender?
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Male
Female
Other gender
What was your sex when you were born?
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Male
Female
Prefer not to answer
Are you currently pregnant or trying to become pregnant?
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Yes
No
Primary Phone Number:
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Okay to leave message at this number?
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Yes
No
What is your email address?
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What is your preferred method of communication?
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Are you willing to travel to Stanford for a study visit?
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Yes
No
Do you have a social security number that enables you to work in the US? (We ask this question to ensure you will be eligible to receive payment.)
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Yes
No
Are you currently enrolled in any research studies?
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Yes
No
What is your native language?
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English
English and another language(s)
Another language(s)
Do you meet the following criteria:
(a) Between the ages of 18-55
(b) Have used ketamine two or more times since you were 18
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Yes
No
Have you ever been diagnosed with any of the following:
Psychotic Disorder such as schizophrenia
Bipolar Disorder
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Yes
No
Do you have a current diagnosis of any of the following:
Depressive Disorder
Anxiety Disorder
Eating Disorder
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Yes
No
Are you currently receiving treatment (e.g., psychotherapy and/or medication) for any mental health related issues?
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Yes
No
Do any of your first-degree relatives have a diagnosis of schizophrenia?
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Yes
No
Please select yes if any of the following apply to you for the last 12 months, regarding use of any illicit drugs or alcohol: (if none of these apply to you, please select no)
Taking the substance in larger amounts or for longer than the you intended
Wanting to cut down or regulate using the substance but not being successful
Spending a lot of time getting, using, or recovering from use of the substance
Intense desire or urges to use the substance
Not being able to fulfill work, home, or school obligations, because of substance use
Continuing to use the substance, even when it causes problems in relationships or makes problems worse
Giving up important social, occupational, or recreational activities because of substance use
Repeatedly using the substance, even when it is physically hazardous
Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
Needing more of the substance to get the effect you want (tolerance)
Development of withdrawal symptoms, which can be relieved by taking more of the substance
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Yes
No
Please select yes if you experienced any of the following in the past month . If none of these apply to, please select no.
I felt sad, empty, or hopeless
I had little energy to complete daily activities
I felt worthless or guilty, and was putting myself down
I get scared and have significant anxiety when I'm in social situations
I was especially anxious and worried about routine things in my life
I was worried about situations in which I might panic and make a fool of myself
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Yes
No
Are you claustrophobic? Or do you feel extremely uncomfortable in enclosed spaces?
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Yes
No
If yes, would you be able to undergo a session in which you would be lying down in an MRI scanner for about two and a half hours (with a break in between)?
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Yes
No
Any personal history of epilepsy, convulsions, or seizures?
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Yes
No
If yes, please provide details (i.e., duration, severity, frequency, etc.).
Do you have any tattoos (especially near the head) or "permanent make-up" (e.g., tattooed eyeliner or eyebrows)?
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Yes
No
Not Sure
If yes or unsure, please indicate the approximate location, size, when the procedure was done, and in what country the procedure was done in.
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Do you have any piercings that cannot be removed?
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Yes
No
Not Sure
If yes or unsure, please provide details regarding your piercing(s).
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Do you have any metal in the body other than dental fillings (e.g., orthodontic braces or permanent retainers, joint pins, shrapnel, etc.)?
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Yes
No
Not Sure
If yes or unsure, please provide details (i.e., what it is, what it is made out of, where it is in your body, etc.).
Do you have a pacemaker or any other implanted devices (e.g., IUDs, breast implants, cochlear impants, neurostimulators, intracardiac lines)?
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Yes
No
Not Sure
If yes or unsure, please indicate the location, size, purpose, composition, manufacturer, date placed in the body, and country of the procedure.
Have you ever worked with metal (as a machinist or as a hobby)?
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Yes
No
If yes, please indicate exposure date, duration & frequency, presence of safety gear (e.g., goggles if welding, etc.).
Do you wear hair extensions or a hairpiece?
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Yes
No
If yes, please indicate if it is removable, and whether the you are willing to remove it for the MRI scan.