Inclusion/Exclusion Screening

Inclusion/Exclusion Screening
Full Name:*

First NameLast Name
Email:*

Confirmation Emailexample@example.com
Phone Number:*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinician Name:*

First NameLast Name
Clinical Site:*
Do you have a diagnosis of Parkinson's disease?*

YesNo
Have you been diagnosed for more than 4 years?*

YesNo
Are you taking any medications for Parkinson's?*

YesNo
Do you have DBS (deep brain stimulation)?*

YesNo
Are you currently in a clinical trial?*

YesNo
Are you planning to get pregnant?*

YesNoN/A
Are you able to walk with or without assistance?*

I need assistance to help me walkI do not need assistance to help me walk
Do you experience hallucinations?*

YesNo
Have you ever been diagnosed with cancer?*

YesNo
Do you have known kidney disease?*

YesNo
Do you have known liver disease?*

YesNo
Do you have a heart condition?*

YesNo
Do you have HIV?*

YesNo
Should be Empty: