Using our Brains Enquiry Form

Thank you for your enquiry regarding becoming a brain donor with the Using our Brains Donor Program. In order to proceed with your enquiry into UoB, could you please respond to the following questions.

Please note that UoB has specific participation criteria and is not able to accept everyone's generous donation.

The answers to these questions will be held in the strictest confidence, and destroyed if you decide not to proceed with enrolment and consent.

Contact Details

 

Full Name: *

Sex: *

Female

Male

Date of Birth: *

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  / 
day

January February March April May June July August September October November December
month

year

Home Phone: 

Mobile Phone: 

Work Phone: 

Address: *

Postal Address: 

Email: *

Preferred mode of contact: 

Email

Post

Phone

General Questions

 

How did you hear about 'Using our Brains' Donor Program? *

Please select an option Internet Family Friend Medical Practioner TV Radio Advertisement News article Other

If Other, please state: 

Are you an Australian resident or citizen? *

Yes

No

Are you a whole body donor? *

Yes

No

A whole body donor is where you have consented, usually with a university program, to donate your entire body research. This is different to organ donation.

Medical and Lifestyle History

 

Have you ever been diagnosed with the following conditions?

An infectious disease such as Hepatitis, HIV, AIDS, CJD? *

Yes

No

If Yes, Details: 

Have you ever experienced a head injury with loss of consciousness? *

Yes

No

If Yes, Details: 

Have you ever experienced a stroke? *

Yes

No

If Yes, Details: 

Have you ever experienced epilepsy? *

Yes

No

If Yes, Details: 

Have you ever used recreational or illicit drugs? *

Never

Previously

Currently

If Yes, Details: 

A mental ilness? *

Yes

No

If Yes, Details: 

If you indicated in the above question, that you have Schizophrenia or Schizoaffective Disorder, are you part of the Australian Schizophrenia Research Bank? *

Not Applicable

Yes

No

Dementia or Alzheimer's Disease? *

Yes

No

If Yes, Details: 

Parkinson's Disease? *

Yes

No

If Yes, Details: 

Multiple Sclerosis? *

Yes

No

If Yes, Details: 

Other Neurological Illness? *

Yes

No

If Yes, Details: 

Do you have any other major health problems? *

Yes

No

If Yes, Details: 

Please list the name and dosage of any medications you take on a regular basis: *