Screening Questionnaire

A study on non-invasive brain stimulation and how it affects movement and speech

For more information, you can refer to this pamphlet: tDCS-pamphlet

This questionnaire is for a research study relating to non-invasive brain stimulation, also known as transcranial direct current stimulation (tDCS), and how it affects different aspects of stuttering. The following video is great introduction to the concept: tDCS-video

This study consists of two 1-hour sessions, one week apart. You can also contact us if you wish to attend only one session. You will receive a gift certificate for each session you attend.

If you have any concerns or questions, please fill out the last part of the questionnaire and note the question number.

Thank you for your interest in our study!

Question Title

* 1. Please state your name and form of contact (i.e., email and/or phone number)

Name *

Email Address *

Phone Number

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* 2. What is your preferred mode of contact?

Text

Call

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* 3. What is your current age (in years)?

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* 4. What is your gender?

Female

Male

Other (specify)

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* 5. Do you consider yourself to have developmental stuttering?
Developmental Stuttering is the form of stuttering that occurred in childhood. If your stutter occurred during your childhood years and persisted onto adulthood, Select "yes".
This is different from acquired/neurogenic stuttering which is the type of stuttering that forms due to a brain injury such as surgery, concussion, or aphasia.

Yes

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* 6. Are you right-handed?

Yes

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* 7. Are you pregnant?

Yes

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* 8. Have you ever participated in the following types of studies within the past 12 months?

A finger-sequencing/typing task

A serial reaction time task study

An alternate serial reaction time task study

A tDCS study

None of the above

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* 9. Please indicate if you currently have any of the following (please scroll all the way to the right for N/A)

Speech disorders that is NOT developmental stuttering (such as aphasia, neurological stuttering, etc.)

Motor disorders (i.e., Parkinson's, dystonia, ataxia, etc.)

Memory-related disorders (i.e., Alzheimer's, memory loss, etc.)

Hearing Loss

Smoker (cigarettes, tobacco products)

Neurodegenerative disorders (i.e., Alzheimer's, Schizophrenia, etc.)

Taking medication for any form of anxiety disorders (i.e., generalized anxiety, social anxiety, etc.)

Taking medication for any form of neurocognitive disorders (i.e., ADHD, OCD, ASD etc.)

Taking medication for mood disorders (i.e., depression, bipolar disorder, etc.)

Other neurological or psychiatric disorders not listed

History of Seizures

Cranial bone defects (i.e., skull bone defects)

Cranial/brain implants

Skin Lesions

None of the Above

If you answered yes to any condition aside from N/A, please indicate the severity of the condition and list the medications you take for each condition:

Screening Questionnaire

Question Title

* 1. Please state your name and form of contact (i.e., email and/or phone number)

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* 2. What is your preferred mode of contact?

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* 3. What is your current age (in years)?

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* 4. What is your gender?

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* 6. Are you right-handed?

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* 7. Are you pregnant?

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* 8. Have you ever participated in the following types of studies within the past 12 months?

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* 9. Please indicate if you currently have any of the following (please scroll all the way to the right for N/A)

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* 10. Do you have any other comments, questions, or concerns?