Questionnaire for Potential Subjects

If you are interested in participating in research studies for spinal cord injury, stroke, acquired brain injury or MS, please fill out the form below:

Age

First Name

Last Name

Address

City

State

Zip Code

Phone

Alternate

Preferred method for contacting you?

Is there a best time to contact you?

What is your diagnosis?

If Other, please describe:

If ABI, what best describes you:

If Other, please describe:

If SCI, please indicate which of the following best describes you:

Complete (ASIA A) Sensory incomplete Only (ASIA B) Sensory and Motor Incomplete - not walking (ASIA C or D) Sensory and Motor Incomplete - walking (ASIA C or D)

If SCI, do you know your level of injury?

If Yes, please describe:

If MS, please indicate what form of MS you have:

When was your injury or diagnosis?

Mechanism/cause of injury

Do you have any other significant medical issues or other diagnoses that we should be aware of, such as high blood pressure, diabetes, cardiac pacemaker, stroke, cardiac disease, skin breakdown, etc.?

Have you ever been seen at Shepherd Center?

Is there a specific area of research that you are interested in, such as drug studies, device studies, cellular studies vs. curative studies or therapy intervention studies?

If Yes, please describe:

Have you ever participated in research?

If yes, you:

Name of Study

Questionnaire for Potential Subjects

In this section

Research