This is a screening questionnaire which can be completed either as a self-report, over the phone, or in person.
Items in BLUE are not visible to the participant in the self-report screening questionnaire and may need to be completed by study staff.
If the staff administering this questionnaire recieves an answer at any time which excludes the respondent from the study, they may end the screening. In this case, any remaining questions can be left blank.
Thank you for expressing interest in our research! Please read the description of the study below carefully before filling out the screening form.
This study is being done to learn more about your brain processes, and how a type of brain stimulation device called TMS can be used to enhance treatment for certain types of drug addiction. Transcranial magnetic stimulation (TMS) is a safe, non-invasive application of a magnetic field to the head. It is used to briefly excite some brain areas and record the outcome. We use noninvasive sensors (electroencephalogram, EEG) placed on the head and face to record the responses of the body. This study takes about one week, with 2 visits to our lab at the University of Minnesota. At these visits you will be asked some questions (demographics, substance use history, mental health, and medical history) and you will complete some cognitive tests on a computer. We will also collect Magnetic Resonance Imaging (MRI) at one of these visits, where you will be asked to lay still in the MRI machine for about 1 hour.
We will collect a urine sample at each study visit to test for drug use in the past 2 weeks and pregnancy (if applicable).
This is a basic schedule of events for the study: Visit 1 (Questionnaires and MRI scan): 4-5 hours Visit 2 (TMS configuration and session): 3-4 hours
You will be paid up to $200 if you attend all visits.
This brief survey asks questions to help us determine if you might be eligible for this study. What you submit in this survey is kept confidential in a HIPAA compliant online portal. If you decide you are not interested in participating, you are free to exit the survey at any time by closing the window in your web browser. Please take about 5 minutes to fill out this survey and we will contact you as soon as possible to let you know if you might be eligible to participate. Thank you!
Today M-D-Y
How did you hear about this study?
If "other," please specify:
First Name:
* must provide value
Last Name:
* must provide value
Phone Number (primary):
* must provide value
Phone number (secondary):
Optional
Email address
* must provide value
Do you prefer to be contacted by phone call or email?
* must provide value
Phone Email No preference
Best day and/or time to call:
Anything else we should know about how to contact you?
Optional
Date of birth:
* must provide value
Today M-D-Y
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Sex assigned at birth
* must provide value
male
female
other (e.g. intersex)
Gender
* must provide value
male
female
other (e.g. nonbinary)
Which pronouns do you prefer?
* must provide value
he/him
she/her
they/them
other (please specify)
Refuse to answer/Don't know
Preferred pronouns (other):
Are you right-handed or left-handed?
* must provide value
Right
Left
Ambidextrous
Are you currently in treatment for a substance use disorder (drug or alcohol dependence/addiction)?(for example: inpatient, residential, outpatient, regular AA/NA)
* must provide value
Yes
No
Have you ever been in treatment for a substance use disorder (drug or alcohol dependence/addiction)?
* must provide value
Yes
No
What is/was your primary substance or drug of choice (DOC)?:
Please write your top preferred substance.
If you have more than one DOC, choose the substance which has most recently been the most disruptive or problematic for you.
* must provide value
Is Stimulant Use Disorder (SUD) likely a primary substance use disorder? The primary treatment must be for stimulants.
If other primary DOCs are identified, ask questions to determine if a stimulant is either the most disruptive or tied for most disruptive along with others.
Yes
No
What was your last date of substance use?
On what day did you most recently use drugs or alcohol? (n ot including nicotine or caffeine)
* must provide value
Today M-D-Y
# of days since last use:
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Are you currently court mandated to a treatment program, incarcerated, or on prison furlough?
* must provide value
Yes
No
The following questions are for potential healthy controls only
Do you drink alcohol?
* must provide value
Yes
No
What are your drinking habits like?
* must provide value
Have you ever used any street drugs?
* must provide value
Yes
No
What drugs have you used and how often have you used them?
* must provide value
How long do you plan to stay in treatment and what will you do after that?
Let us know whatever you can about your treatment plans. It's okay if you're not sure yet.
For example: "I started a 1 year inpatient program last month" or "I leave inpatient on June 1st and will start IOP after that" or "I'll be in outpatient for at least 3 more months", etc.
* must provide value
Are you available to attend 4 study visits over 2 weeks?
* must provide value
Yes
No
If "No," is there a time when you would be available?
Do you (or have you ever) used tobacco or nicotine products regularly?
Include only habitual use (>100 cigarettes lifetime)
* must provide value
Yes, cigarettes only
Yes, including products other than cigarettes (vape, pipe, etc.) habitually
No
How many cigarettes per day (on average)?
* must provide value
How many years have you used tobacco?
* must provide value
Pack years:
If non-cigarette tobacco has been used habitually, pack years cannot be counted
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Have you ever received a diagnosis for any of the following mental health conditions? (please select all that apply)
* must provide value
Other mental health conditions (please specify):
* must provide value
Optional
If you have any current medical problems or conditions, please list them here:
Do you currently use medical marijuana prescribed by a healthcare professional?
* must provide value
Yes
No
Optional
Have you ever been knocked unconscious for over 30 minutes?
* must provide value
Yes
No
Any other history of neurological problems (concussions, TBI, tumor in nervous system)?
* must provide value
Yes
No
Have you ever had a seizure or convulsion?
* must provide value
Yes
No
Optional
As part of the study, we will administer Transcranial Magnetic Stimulation (TMS). Do you know of any reason you could not tolerate TMS?
* must provide value
Yes
No
Have you participated in any other research in the past year?
* must provide value
Yes
No
Have you ever had ECT, cortical energy exposure, or any neuromodulation treatment?
* must provide value
Yes
No
Research and neuromodulation notes:
Optional
Screen passed
Not eligible
Eligibility uncertain
Screen not completed
"Other" reason not eligible:
Explain uncertain eligibility:
Excluded due to one or more of the following criteria:
Optional
Optional
Screener name or initials: