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INFORMATION PROVIDED IN THIS FORM WILL REMAIN CONFIDENTIAL. INFORMATION ABOUT YOU WILL BE AVAILABLE ONLY TO THE RESEARCHER IN CHARGE OF THIS PROJECT.

Last name First name Middle Initial

Date of Birth (MM/DD/YYYY) Sex

Street Address Apt./Suite #

City State ZIP+4 (no dashes)

Email Address Retype Email Address

Home Phone Other Phone

Preferred Method of Contact
Please describe your race:
African-American (non-Hispanic)
Asian or Pacific Islander
American Indian or Alaskan Native
Caucasian (non-Hispanic)
Hispanic
Other (please specify)
Please describe your handedness:
Left
Right
Ambidextrous
Select the first language you learned Select the language you speak most of the time
Please check any and of all of the following that apply to you:
Hearing Problems
Hearing Aid
Language Problems
Speech Problems
Reading Problems
Remedial Reading Classes
Attention Problems
Neurological Condition
Psychological Problems
Please describe your vision status:
Normal without glasses/contacts
Corrected by glasses/contacts to normal
Vision impairment with glasses/contacts--Please specify

Have you ever had corrective surgery for your eyesight?
Have you ever been admitted to the hospital (overnight)?

If yes, please describe:
Are you currently taking prescription medication?
Additional Comments

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