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Please verify the patient demographic information on the Demographics Verification form.
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Have you submitted a previous Cellular Therapy Inquiry survey response for this patient?
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Yes No
Is this child's umbilical cord blood stored in a public or family cord blood bank?
OR
If you are 18 years of age or older, and wish to participate in one of our studies, is your umbilical cord blood stored in a cord blood bank?
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Yes
No
If yes, where?
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Did you bank your child's cord tissue?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, is your cord tissue stored in a bank?
Yes
No
If yes, where?
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Are any of your other children's umbilical cord blood stored in a public or family cord blood bank?
OR
If you are 18 years of age or older, and wish to participate in one of our studies, are any of your siblings' umbilical cord blood stored in a bank?
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Yes
No
If yes, where?
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Are you (the parent) currently pregnant and planning on storing cord blood in a public or family cord blood bank?
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Yes
No
Estimated Date of Delivery
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Did you bank any of your other children's cord tissue?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, is your sibling's cord tissue stored?
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Yes
No
If yes, where?
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Are your children full sibling?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, are your siblings full siblings?
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Yes
No
Has your child been diagnosed with a genetic disease?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you been diagnosed with a genetic disease?
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Yes
No
If yes, describe:
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Has your child been diagnosed with HIV or Hepatitis B or C?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you been diagnosed with HIV or Hepatitis B or C?
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Yes
No
Does your child need supplemental oxygen or a breathing machine to breathe?
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Yes
No
Has your child ever received any other cell therapy?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you ever received any other cell therapy?
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Yes
No
Other cell therapy
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Has your child ever been diagnosed with cancer or a problem with their immune system?
OR
If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you ever been diagnosed with cancer, or a problem with your immune system?
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Yes
No
What diagnosis or problem?
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First Name
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Last Name (surname)
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Date of Birth
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Date of birth - Do not enter a future date Current Age Year(s) Month(s)
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Has your child been diagnosed with any of the following conditions (check all that apply):
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Other diagnosis
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Is the apraxia associated with any other conditions?
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Yes
No
Describe the other condition(s) associated with apraxia
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How would you describe your child's muscle tone?
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Normal High (ie. spasticity) Low (ie. hypotonia) Mixed Other
Other muscle tone description
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Which of the following best describes the development of your child's motor milestones?
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Early On time Delayed
Does your child have limitations in their motor abilities for their age?
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Yes No
Describe the other limitation(s)
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For each category below, please mark the selection(s) that best describes your child's current motor abilities:
Age < 2 years
Rolling/Crawling:
Sitting: Standing: Walking:
Rolling/Crawling:
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Does not roll or crawl
Rolls front to back
Rolls back to front
Rolls on the floor from one spot to another
Creeps on stomach ("army crawl")
Crawls on hands and knees
Sitting:
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Unable to sit independently
Requires adaptive equipment to sit
Floor sits, needs to use their hands for support
Floor sits with both hands free to manipulate objects
Moves in and out of sitting position without assistance
Standing:
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Does not stand
Requires adaptive equipment to stand
Pulls to stand on a stable surface
Cruises holding on to furniture
Walking:
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Does not walk
Walks using an assistive device
Prefers to walk and does so independently without assistance from a person or device
For each category below, please mark the selection(s) that best describes your child's current motor abilities:
Age 2 - < 4 years
Rolling/Crawling:
Sitting: Standing: Walking: Most commonly used method of independent mobility:
Rolling/Crawling:
* must provide value
Does not roll consecutively or crawl
Rolls on the floor from one spot to another
Creeps on stomach ("army crawl")
Crawls on hands and knees
Sitting:
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Unable to sit independently
Requires adaptive equipment to sit
Floor sits, needs to use their hands for support
Typically "W-sits" on the floor
Floor sits with both hands free to manipulate objects
Requires adult assistance to assume sitting position
Moves in and out of sitting position without assistance
Standing:
* must provide value
Does not stand
Requires adaptive equipment to stand
Pulls to stand on a stable surface
Cruises holding on to furniture
Walking:
* must provide value
Does not walk
Walks using an assistive device
Prefers to walk and does so independently without assistance from a person or device
Most commonly used method of independent mobility:
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No independent mobility
Rolling from one spot to another
Creeping on stomach ("army crawl")
Crawling on hands and knees
Walking with an assistive device
Walking independently
For each category below, please mark the selection(s) that best describes your child's current motor abilities:
Age 4 - < 6 years
Sitting: Getting in and out of a chair: Walking: Most commonly used method of independent mobility:
Sitting:
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Unable to sit independently
Requires adaptive equipment to sit so they can use their hands
Sits in a chair without assistance with both hands free to manipulate objects
Getting in and out of a chair:
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Needs adult assistance
Uses hands or arms for support
Gets in and out of a chair independently without hand support
Walking:
* must provide value
Does not walk
Walks short distances using a walker
Walks with a hand-held mobility device
Walks independently without assistance from a person or device
Most commonly used method of independent mobility:
* must provide value
No independent mobility
Powered wheelchair
Rolling from one spot to another
Creeping on stomach ("army crawl")
Crawling on hands and knees
Walking with an assistive device
Walking independently
For each category below, please mark the selection(s) that best describes your child's current motor abilities:
Age 6+ years
Sitting: Walking: Most commonly used method of independent mobility:
Sitting:
* must provide value
Unable to sit independently
Requires adaptive equipment to sit
Sits in a chair without assistance
Requires assistance to get into a sitting position (floor or chair)
Gets in and out of a chair without hand support
Walking:
* must provide value
Does not walk
Walks short distances with physical assistance
Walks with a body support walker
Walks short distances using a walker
Walks with a hand-held mobility device
Walks independently without assistance from a person or device
Most commonly used method of independent mobility:
* must provide value
No independent mobility
Powered wheelchair
Manual wheelchair
Rolling from one spot to another
Creeping on stomach ("army crawl")
Crawling on hands and knees
Walking with physical assistance
Walking with an assistive device
Walking independently
Patient's weight (in pounds)
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pounds
Date Weight Obtained
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Male Female
American Indian/Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one Race
Ethnicity
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Hispanic or Latino Not Hispanic or Latino
Relationship
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Mother Father Self (Patient, >= 18 years of age) Aunt Uncle Grandmother Grandfather Legal Guardian
First Name
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Last Name
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Date of Birth
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Primary Email Address
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Confirm Email Address
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Email addresses do not match. Please correct.
Phone
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Optional If Participant is 18 years of age or older Phone
Optional If Participant is 18 years of age or older Email Address
Street Address
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State field will appear after Country is selected. Country
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State
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
State/Province
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Zip Code
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Yes
No
Contact 2
Parent, Legal Authorized Representative or Emergency Contact
Mother Father Aunt Uncle Grandmother Grandfather Legal Guardian
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Yes
No
State field will appear after Country is selected. Afghanistan ?and Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic of Cook Islands Costa Rica C??d'Ivoire Croatia Cuba Cura? Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar R?ion Romania Russian Federation Rwanda Saint Barth?my Saint Helena Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Saint-Martin (France) Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Netherlands Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe
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Patient First Name ______ Patient Last Name (surname) ______ Patient Date of Birth ______ Patient Diagnosis ______ ______ Primary Email Address ______