Microsoft word - screening_eng(2012).doc

DEMOGRAPHIC QUESTIONNAIRE

Date/Experimenter_____________________________________________
Screening: General Demographic information
REMIND POTENTIAL SUBJECT: CONFIDENTIAL
Subject code assigned if approved ________________
Have you ever participated in a study at the Centre for Studies on Human Stress?
If so, can you recall what it entailed?
_____________________________________________________________

Hours Per Week? Employment Title/Department Education Civil Status:
❒ Single ❒ Married ❒ Common Law ❒ Separated ❒ Divorced ❒ Widowed
General Medical Information:
Smoker? ________ Social_______ If yes, how many per day?_________ How man cups of caffeine do you have per day? __________ 2012 Centre for Studies on Human Stress How many alcoholic drinks per day? _____ per week _____ Elicit drug use? _________ If yes, frequency and nature of the drug _________________ If yes, frequency and nature of drug(s)_________________________________________ REMIND POTENTIAL SUBJECT: CONFIDENTIAL

Do you currently suffer from or have you ever had:
Allergies

Cardio-vascular
Heart attack
Other __________________
Neurological
Stroke

General Problems
Diabetes
Infectious illness/sexually transmitted diseases Intestinal inflammatory disease (ex. Crohn’s Disease)  Inflammatory Bowel Disease or Syndrome ___________________
2012 Centre for Studies on Human Stress REMIND POTENTIAL SUBJECT: CONFIDENTIAL

Psychiatric problems (present or past or in 1st degree relatives)

Depression
 (talk it out with the subject, give examples…)
Have you had a cold or flu in the last 12 months _______________________

Do you take any Medication?
!!Contraceptives
 (pill, patch, *IUD)
 (thorazine, haldol, largactil, clozaril) !Anti-depressants
 (for sleep disturbances, PMS, smoking cessation) !Anxiolytics
 Prozac, Paxil, Pexeva, Zoloft, Effexor, Wellbutrin, Parnate  (creams, nasal spray, ventilator/pump asthma cortisone, prednisone, flonase…) Other ( ________________________________________________________________) 2012 Centre for Studies on Human Stress
(Only for WOMEN)
!! What type of Contraceptive do you take? ______________________________
!! What is the brand name of your Oral Contraceptive? ____________________
!! How many milligrams do you take? _______________________________
!! What color is your pill? _______________________________

!! When was your last period?
_______________________________

!! Menopause? At what age?
_______________________________

Have you had general anesthesia or surgery in the last year? ________________
Have there been any major life events in the past year? (Example: breakup, death in the
family, difficulty in school)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Consent to pass your name on for other studies (Yes/No)______________
2012 Centre for Studies on Human Stress

Source: http://www.humanstress.ca/documents/pdf/SalivaLab/Screening_ENG(2012).pdf