How to Volunteer

 

To Volunteer you must:

  1. Fill out the form at the bottom of this page
    • All personal information will be confidential and will not be shared outside the lab
  2. If you are eligible, you will be contacted via email with available appointments
  3. Respond with your appointment choice(s)
  4. If scheduled, you will receive a confirmation email with further instructions

 

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IMPORTANT: Our scans are not of diagnostic quality and cannot be used for medical purposes

 

 

Volunteer Form

 

Name:  

Phone:  

Email:  

Age:    

Gender:     Male     Female  

Handedness:   Right     Left  

 

We scan at both Northwestern Memorial Hospital in Downtown Chicago, and Evanston Northwestern Hospital in Evanston. Please indicate if you would be willing to participate at each of the sites.

NMH (Chicago):     Yes     No  

ENH (Evanston):     Yes     No  

 

It is to your advantage that you should answer the following items truthfully as some of these metals may cause some bodily harm when in the scanner. Please make a checkmark in the appropriate box next to any items that you may have currently in your body. This is a mandatory screening for all persons who enter the scanning room. If you have any questions, please contact us. Thank you.
Yes: No:
Do you require eyeglasses?
Do you wear contacts?
Have you had any previous MRI?
Is English NOT your first language?
Do you have any metal fragments in eyes/skin/body (shrapnel) or metal plates/pins/screws/wires?
Have you ever had eye surgery or had your eyes washed out because of metal?
Do you have a cardiac pacemaker or neuro-stimulator?
Do you have any prosthetic limbs?
Have you had surgery requiring aortic/aneurysm clips, by-pass surgery, coronary artery clips or a heart valve replacement?
Do you wear a hearing aid?
Are you now or have you ever been a metal worker/welder (even as a hobby?)
Are you in the first trimester of pregnancy or trying to become pregnant?
Do you use a metal I. U. D. (birth control device)
Do you have any neurological history?
Are you currently undergoing psychiatric treatment or taking prescription psychoactive drugs (including antidepressants)?
If you answered "Yes" for any of the above questions, please explain:
Body piercings can complicate the MRI procedure. Please list all body piercings, their locations, and whether or not they are removable:
Please list all dental hardware (retainers, bridges, etc.) and whether or not they are removable:

 

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