Enrol for Cerebral Space

Enrolment Code

First Name

Last Name

Email Address

Either your email address, or one of your parent's

Age

Gender

Female Male

Height (in cm)

Weight (in kg)

Handedness

Right Left Ambidextrous

Have you been diagnosed with one of the following learning disorders?

ADHD Dyslexia Dyscalcula

Other:

Are you currently enrolled in a cognitive remediation programme, or have you been enrolled in the past?

Yes (currently) Yes (previously) No

If you answered 'yes' to the previous question, what is the name of the programme?

Do you have any history of epileptic seizures?

Yes No

Do you have any history of brain trauma?

Yes No

Is English your native language?

Yes No

How would you characterize your experience with video gaming?

None Limited Fair Extensive

How often do you exercise?

Rarely Sometimes Regularly Very often

Your ability to excel at school is something about you that you cannot change very much.

To what extent do you agree with this statement?

Strongly disagree Disagree Somewhat disagree Somewhat agree Agree Strongly agree

You have certain abilities that help you in your schoolwork and you cannot do much to change it.

To what extent do you agree with this statement?

Strongly disagree Disagree Somewhat disagree Somewhat agree Agree Strongly agree

How happy would you say you are at the moment?

Not at all Not so much Fairly Quite Very Extremely

How would you best describe your sleep quality at the moment?

Very poor Poor Fair Good Really good Excellent

How would you characterize your health at the moment?

Very poor Poor Fair Good Really good Excellent