Thank you for your interest in our stroke recovery studies. Please take a moment to answer the questions below.

1. Patient Information:

Patient's Name:
Date of Birth:




Gender:

male     female




Street Address:
City:
State:
Zip:

2. Contact Information:

Contact Person's Name:
Relationship to Patient
Email Address:
Phone Number:
Cell Number:

3. Prior to stroke, the patient was:

right-handed     left-handed     ambidexterous

4. Date of Stroke:

Was this his/her first (and only) stroke?     yes     no     uncertain

5. Which part of the brain was affected by the stroke?

right     left     brainstem     uncertain

6. Which side of the body was affected by the stroke?

right     left     both    

7. On the affected side, please indicate the type of movement that s/he currently has in the:

8. On the affected side, his/her muscle tone could be described as:

flaccid (loose, floppy)
spastic (stiff, tight)
normal

9. Was his/her ability to speak affected by the stroke?

yes     no    

10. Does s/he have any difficulty understanding language?

yes     no     minor     uncertain

11. Prior to the stroke did s/he speak English fluently?

yes     no

12. Can s/he repeat any words?

yes     no

13. Has the patient ever had an MRI?

yes     no     If yes, please give the date of most recent MRI:

14. Are there reasons the patient cannot have an MRI?

yes     no     If yes, please specify:

15. Has s/he ever had:

16. Would s/he be able to come to BIDMC for assessment, and if eligible, for treatment in our stroke recovery trial?

yes     no

17. If s/he is not eligible for our current studies, may we keep his/her information on file for future studies?

yes     no