First Name
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Last Name
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Year of Birth
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(e.g., 1975, 2001)
AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV- Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming
Zip Code
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Please enter country of residence.
Phone Number
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Please enter 10 digit # in this format (404)352-2020
Email
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If you do not use email, please enter "noemail@shepherd.org"
How do you prefer to be contacted?
Phone by voice call
Phone by text/SMS
Email
Mail
What is the best time of day to contact you?
Morning (8am -12pm)
Afternoon (12pm -4pm)
Evening (4pm -8pm)
What best describes your current occupation? (check all that apply)
Other Occupation: Please describe.
What is your diagnosis?
* must provide value
Spinal Cord Injury (SCI)
Dual Diagnosis: Spinal Cord Injury (SCI) + Brain Injury
Brain Injury / Stroke / Concussion
Multiple Sclerosis (MS)
Other
Other Diagnosis. Please describe.
If you have a Brain Injury, please select which of the following best describes your injury;
Concussion, or mild Traumatic Brain Injury
Traumatic Brain Injury (moderate/severe)
Stroke
Non-traumatic brain injury (other than Stroke)
I don't know
If you have a Spinal Cord Injury (SCI), please select which of the following best describes your injury:
Complete (ASIA/ISNCSCI A)
Sensory incomplete Only (ASIA/ISNCSCI B)
Sensory and Motor Incomplete - not walking (ASIA/ISNCSCI C or D)
Sensory and Motor Incomplete - walking (ASIA/ISNCSCI C or D)
I don't know
What was the date of your last ASIA/ISNCSCI exam?
If SCI, please indicate your level of injury
C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 Below T12 Not sure/I don't know
select highest level of injury
If you have Multiple Sclerosis (MS), please select which of the following best describes the form of MS you have:
Relapsing / Remitting MS (RRMS)
Primary Progressive MS (PPMS)
Secondary Progressive MS
Other
If Other, please describe:
Are you currently taking any disease modifying therapy (DMT)?
Yes
No
Which disease modifying therapy (DMT) are you currently taking?
Ocrevus (ocrelizumab)
Tysabri (natalizumab)
Kesimpta
Copaxone
Rituxan (rituximab)
Gilenya (fingolimod)
Other
If "Other", please describe your disease modifying therapy (DMT):
What year were you injured or diagnosed?
* must provide value
Please provide the year
How were you injured? (i.e., mechanism or cause of injury)
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Sports or recreational activity
Motor vehicle accident / Motorcycle accident
Fall or hit by falling or flying object
Violence or assault
Gunshot wound
Tumor
Blast
Other
Not Applicable
If Other, please describe:
What is your primary mode of mobility?
Walking
Walking with orthotic devices
Manual wheelchair
Power wheelchair
Scooter
Other
Please describe "Other" primary mode of mobility.
If you are walking, which of these mobility aids do you use? (check all that apply)
How far can you walk without needing to use an aid (cane, crutch, walker) or rest?
More than 1500 feet (500 meters OR 7 city blocks OR 1/3 of a mile OR about 5 football fields)
At least 900 feet (300 meters OR 4 city blocks OR 1/5 of a mile OR about 3 football fields)
At least 600 feet (200 meters OR 2.5 city blocks OR 1/10 of a mile OR about 2 football fields)
At least 300 feet (100 meters OR 1 city block OR about 1 football field)
Less than 300 feet
Not at all
When you use an aid (cane, crutch, walker), how far can you walk?
300 feet (100 meters OR 1 city block OR about 1 football field)
60 feet or 20 meters
15 feet or 5 meters
Only a few steps
Not at all
Briefly describe any other significant medical issues or other diagnoses, such as high blood pressure, diabetes, stroke, cardiac disease, skin breakdown, etc. you have?
Briefly describe any implanted medical devices and stimulators, such as cardiac pacemaker, epidural stimulator, baclofen pump, etc. you have.
Have you ever been seen as a patient at Shepherd Center?
Yes
No
Have you ever participated in research?
Yes. Shepherd Center research studies.
Yes. Research studies with another organization.
Yes. Both with Shepherd Center and with another organization.
No. I have not participated in any research.
Name(s) of research studies in which you have participated.
What types of research studies are you interested in participating? (check all that apply)
Research Interests Other. Please describe.
Which, if any, of the following challenges or limitations do you have? (check all that apply)
Which, if any, of the following aids do you use? (check all that apply)
Which, if any, accessibility features do you use on your Information Communication Technology (ICT) devices (e.g., mobile phones, laptops, computers, tablets)? (check all that apply)
I do not use any accessibility features
Built-in screen reader (VoiceOver, Talkback, Narrator)
Third-party screen reader (JAWS, MAGic, Talks)
Gesture-based controls (tilting device, waving your hand in front of device)
Simple display
Large icons
Text magnification (zoom text, font size settings)
Screen magnification (magnifies the entire screen)
High contrast or color adjustment
Autocorrections and autocapitalizations
Word prediction software
Subtitles & captioning
Visual alerts
Auditory alerts
Switch control or switch access
Alternate control to access physical buttons, settings, or favorite apps (Assistive Touch, Assistant Menu, Voice Access)
Incoming calls to headset or speaker
Intelligent personal assistant (Cortana, Google Now, Siri)
Text-to-speech technology
Speech-to-text technology (Dragon Naturally Speaking)
Hearing aid mode
Alternative keyboards (Swype)
Sticky Keys
Do you experience muscle spasms?
Yes
No
How often do you have muscle spasms?
Fewer than 1 time per day
1 to 5 times per day
6 to 9 times per day
10 or more times per day
I am interested in research regarding:
Arm spasticity
Leg spasticity
Both
Neither
Do you experience muscle stiffness?
Yes
No
When does muscle stiffness impact your daily routine and activities? (check all that apply)
I have stiffness in my: (check all that apply)
Do you agree to have your information placed in a database so that we may contact you about possibly participating in research studies?
* must provide value
Yes
No