HPP LAB SURVEY
Name: __________________ e-mail address: __________________
Phone number: __________________ Age: ____________ Sex:__________
Weight (in pounds): _______________ Height: __________
Best Time to Call: ________________ Are you a U.S. Citizen?___________
How did you hear about the study? _______________________________________
Number of Years of Education ______ (high school graduate = 12, plus number of completed years of college and graduate work)
Handedness: Right-handed Left-Handed
Please circle one answer per question.
How many times in the past 12 months have you done the following:
1. Played a PC based video game?
1 time or less 2-10 time 10-30 times 30-60 times more than 60 times
2. Played a console video game system (e.g., Playstation, X-Box, Wii, etc…)?
1 time or less 2-10 time 10-30 times 30-60 times more than 60 times
3. Played a video game in an arcade?
1 time or less 2-10 time 10-30 times 30-60 times more than 60 times
4. Played an online java-script video game (e.g., www.popcap.com)
1 time or less 2-10 time 10-30 times 30-60 times more than 60 times
6. Do you consider yourself to be an active video game player?
Yes No
7. During an average week, how many hours will you spend playing video games ?
< 1 hour 1-3 hours 3-5 hours 5-7 hours 7-9 hours > 9hours
8. How often did you play video games as a child?
Never Seldom Sometimes Frequently Often
9. Do you own a personal computer?
Yes No
10. Please list any videogame systems in your household:
________________________
________________________
________________________
________________________
________________________
11. Please estimate the number of hours per week you :
A. Play PC based video games: ____________hrs
B. Play console video games (e.g., Playstation 2, Game Cube, X-Box, etc…): ____________hrs
C. Play video games in an arcade: _________hrs
D. Play online java-script games (e.g., www.popcap.com): __________hrs
Medical Information
These questions pertain to the MRI portion of the study. The MRI is an enclosed space. Thus, if you are claustrophobic you may not participate. Additionally, given that the MRI method involves strong magnetic fields, metallic implants in your body (e.g., pins or screws) may prevent you from participating.
1) Are you claustrophobic?
Yes No
2) Do you have any metallic implants in your body?
Yes No
You must also have normal, or corrected-to normal vision and hearing to participate.
3) Do you have normal, or corrected-to-normal vision and hearing, including normal color vision?
Yes No
Certain psychological and neurological conditions will exclude you from participating and you will be asked about these conditions when we call. If you have a condition or are on a medication that affects your central nervous system (e.g., depression, ADD, ADHD, tourette’s syndrome, schizophrenia, etc..) you cannot participate in the current study.
Scheduling Information
Participation in our study is a significant time commitment and we want to ensure that you will have the time to complete it.
Participation requires that you complete about 26 2-hour sessions over the period of 7 or 8 weeks, starting from mid-September or early October.
Are you a full-time student?
Yes No
If you are a student, how many courses are you taking this semester? _______________
Do you have a job?
Yes No
If so, is this job part-time or full-time?
Part-time Full-time
How many hours a week do you work, if employed: ___________
During weekdays, you are primarily available:
Mornings (8am to Noon) Afternoons (Noon to 5pm) Evenings (5pm to 8pm)
Do you anticipate leaving the Urbana-Champaign area for a period longer than 3 or 4 days this semester?
Yes No
If so, please describe any trips or travel plans for the semester below:
