Cognitive Neuroscience lab - Screening Questionaire

SFiC Questionaire

Please fill in all fields unless stated otherwise.

Name
NRIC Number
Phone
E-mail
Age
Height (cm)
Weight (kg)
Gender	Male Female
Are You Right Handed?	Yes No
Occupation	State current level of education if schooling

Do you have any language impairments? No Yes If yes, please specify

First Language? English Chinese Malay Tamil Others If others, please specify

Second Language? (Must differ from First Language) English Chinese Malay Tamil None Others If others, please specify

Language used most often? English Chinese Malay Tamil None Others If others, please specify

Do you wear prescription glasses and/or contact lenses? No Yes If yes, please specify degree Right: Left:

Do you have high astigmatism? No Yes

Are you color blind? No Yes

Do you have metallic implants?
No Yes Not sure	Braces Dental Retainers Vascular Clips Pacemakers Replacement Joints Skull Plates Tattoo / Body Piercing Jewelry Others If others, please specify

Do you have a history of neurological or psychiatric disorders? No Yes If yes, please specify

Do any of your family members have any history of neurological or psychiatric disorders? No Yes If yes, please specify

Have you gone through any medical surgery before? No Yes If yes, please specify

Do you have any chronic medical illnesses? No Yes If yes, please specify

Are you on any long term medications? No Yes If yes, please specify