Inclusion/Exclusion Screening
Full Name:
*
First Name
Last Name
Email:
*
Confirmation Email
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinician Name:
*
First Name
Last Name
Clinical Site:
*
Do you have a diagnosis of Parkinson's disease?
*
Yes
No
Have you been diagnosed for more than 4 years?
*
Yes
No
Are you taking any medications for Parkinson's?
*
Yes
No
Do you have DBS (deep brain stimulation)?
*
Yes
No
Are you currently in a clinical trial?
*
Yes
No
Are you planning to get pregnant?
*
Yes
No
N/A
Are you able to walk with or without assistance?
*
I need assistance to help me walk
I do not need assistance to help me walk
Do you experience hallucinations?
*
Yes
No
Have you ever been diagnosed with cancer?
*
Yes
No
Do you have known kidney disease?
*
Yes
No
Do you have known liver disease?
*
Yes
No
Do you have a heart condition?
*
Yes
No
Do you have HIV?
*
Yes
No
Submit
Should be Empty: