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About Dal
G‑Study Screening
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English Screening
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G‑Study Screening
English Screening
English Screening
To complete the questionnaire you must first email margaux.ross@nshealth.ca with the subject line "Gstudy website screening". You will then be given a confidential identification code that you will submit below.
Please input the identification code provided to you. If you have not received a code please email margaux.ross@nshealth.ca
*
Which countries have you lived/worked in? (Please also provide dates and duration of stay)
*
Please indicate your sex
No Selection
Male
Female
Other
Please indicate your age
When you have headaches, how often is the pain severe?
*
No Selection
Never
Rarely
Sometimes
Very Often
Always
Which of the following symptoms have you experienced? (Check all that apply)
Headaches
Headaches
Tinnitus (ringing in ears)
Tinnitus (ringing in ears)
Blurred Vision
Blurred Vision
Memory Problems
Memory Problems
Difficulty Concentrating
Difficulty Concentrating
Light Sensitivity
Light Sensitivity
Fatigue
Fatigue
Sleep Problems
Sleep Problems
Vestibular Problems
Vestibular Problems
Balance Problems
Balance Problems
Nausea
Nausea
How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?
*
No Selection
Never
Rarely
Sometimes
Very Often
Always
When you have a headache, how often do you wish you could lie down?
*
No Selection
Never
Rarely
Sometimes
Very Often
Always
In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?
*
No Selection
Never
Rarely
Sometimes
Very Often
Always
In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?
*
No Selection
Never
Rarely
Sometimes
Very Often
Always
In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?
*
No Selection
Never
Rarely
Sometimes
Very Often
Always
Compared with before the incident, do you now suffer from headaches?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from feelings of dizziness?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from feelings of nausea and/or vomiting?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from feelings of noise sensitivity (easily upset by loud noise)?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from sleep disturbance?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from fatigue, tiring more easily?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from being irritable, easily angered?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from feeling depressed or tearful?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from feeling frustrated or impatient?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from forgetfulness, poor memory?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from poor concentration?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from taking longer to think?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from feelings of blurred vision?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from light sensitivity (easily upset by bright light)?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from double vision?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Compared with before the incident, do you now suffer from restlessness?
*
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Are you experiencing any other difficulties? If no please leave blank.
Please also provide severity of this issue as compared to before the incident.
Blank
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
Are you experiencing any other difficulties? If no please leave blank.
Please also provide severity of this issue as compared to before the incident.
Blank
No Selection
Not experienced at all
No more of a problem
A mild problem
A moderate problem
A severe problem
