Form 1 Pre-Mortem Donor Recruitment Form

OMB Control Number: 0925-xxxx
Expiration Date: xx/xx/20xx
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this
address.

NIH Neurobiobank
Pre-mortem Donor Recruitment Form
Recruitment of Donors
All fields with an * are required.
First Name First Name*

Last Name Last Name*

Phone Phone* (w/ area code)

E-mail E-mail*

Address Address*

Address 2 Address 2

State*

Zip Zip*

City City*

State

Country Country*

Age Age*
Referral Referred by

Affiliation Affiliation

Questions or comments?

Have you ever seen a doctor for any memory trouble?
Yes

No

Don't Know

Name of Doctor:

What did the doctor say was
Have
the you
cause
everofhad
the an
memory
examination
trouble?with a specialist such as a

neurologist?
Yes

No

Name of Doctor:
Yes

No

Don't Know
Was a CAT Scan or MRI done?
Don't Know

Have you ever been hospitalized for evaluation or treatment of a neurological and/or neuropsychiatric disorder?
Yes

No

Don't Know

What diagnosis was given for
Has
thea cause
doctor of
or the
nurse
problems?
ever told you that you have high blood pressure that should be treated
medically?
Yes

No

Don't Know

Have you ever had a stroke?
Yes

No

Don't Know

Have you had more than one stroke?
Yes

No

Don't Know

When did the stroke (first one)
Is one
take
side
place?
of your body, or one leg/arm weaker that the YES other side?
Yes

No

Don't Know

Have you ever been told that you have Parkinson's disease?
Yes

No

Don't Know

If yes, Date of First Symptom:
Date of Diagnosis:

Date of First Symptom:

Side of first symptom:

you ever had an injury to your head that resulted in the loss of consciousness for more that a few seconds?
Yes

No

Don't Know

When did this first happen? Please describe the times that
Havethis
youhas
everhappened?
been on estrogen replacement therapy?

Have

Yes

No

Not Applicable

Have you ever had any epileptic seizures of fits?
Yes

No

Don't Know

Have you ever had a problem drinking more alcohol than you should?
Yes

No

Don't Know

Did the memory problems coincide with the drinking?
Yes

No

Don't Know

Record any comments regarding
Have you
alcohol
everhistory
been depressed or sad for two weeks or more?
Yes

No

Don't Know

Did you ever seek treatment for the depression?
Yes

No

Don't Know

Do you have mood swings in which you go from being extremely depressed to being excessively happy and energetic?
Yes

No

Don't Know

Were you ever treated, or told you needed treatment for this?
Yes

No

Don't Know

Have you ever sought psychiatric or psychological help for any other reason?
Yes

No

Don't Know

If yes, please explain:
Yes

No

Have you received a whole blood transfusion recently?

Don't Know

Has blood donation been denied in the past, specify below?
Yes

No

Don't Know

If yes, Reason:
Yes

No

Current diagnosis of cancer (regardless of treatment and location)?
Don't Know

Infectious Disease?
Yes

No

Don't Know

Unexplained seizures?
Yes

No

Don't Know

Exposure to toxic substances that may have led to chronic conditions?
Yes

No

Don't Know

Dementia with unknown cause (not from a previous CVA, infection, YES head trauma, or brain tumor)?
Yes

No

Don't Know

Please state your one notable lifetime achievement?

Type the text
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