This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^Pro\d{8}$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[1-3]{5}$/

/^[\s\S]{0,50}$/

/^\d{2}.\d$/

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([0-9]{3})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^[A-Z]{2}\d{4,}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

cYgLxg2r4B4C5gJW7qRcIi4fLz27oMVsM4wapXTMVdZWHJom42fIdcRUsNSbvwFS8KkzxhUMWgZy4IqzrkF4dhySTqUaYon3Q4jJoSFZfgcyWaCTnPMd3JNZt8PtK

Duke Brain Injury Parent Inquiry (NFL)

Please answer the questions below. All categories with red asterisk must be completed. International patients do not need to complete the insurance section, unless you are a U.S. citizen with U.S. health insurance.

DO NOT USE UNTIL POST-PRODUCTION STEPS HAVE BEEN COMPLETED

Please verify the patient demographic information on the Demographics Verification form.

Date/Time Created

M-D-Y H:M

Date Created

M-D-Y

Time Created

H:M

TESTING PURPOSES

Hide fields not necessary for testing

Show all fields in the survey

reset

Have you submitted a previous Cellular Therapy Inquiry survey response for this patient?

* must provide value

Is this child's umbilical cord blood stored in a public or family cord blood bank?

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?

* must provide value

Yes

reset

If yes, where?

* must provide value

Did you bank your child's cord tissue?

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

reset

If yes, where?

* must provide value

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?

* must provide value

Yes

reset

If yes, where?

* must provide value

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?

* must provide value

Yes

reset

If yes, where?

* must provide value

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?

* must provide value

Yes

reset

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?

* must provide value

Yes

reset

If yes, describe:

* must provide value

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?

* must provide value

Yes

reset

Does your child need supplemental oxygen or a breathing machine to breathe?

* must provide value

Yes

reset

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?

* must provide value

Yes

reset

Other cell therapy

* must provide value

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?

* must provide value

Yes

reset

What diagnosis or problem?

* must provide value

Expand

First Name

* must provide value

Middle Name

Last Name (surname)

* must provide value

Date of Birth

* must provide value

M-D-Y

Date of birth - Do not enter a future date �

Current Age
	Year(s)
	�

	Month(s)

Has your child been diagnosed with any of the following conditions (check all that apply):

* must provide value

Autism (ASD, Autism Spectrum Disorder, Aspergers)

Apraxia

Cerebral Palsy

Hydrocephalus/Cerebral Ventriculomegaly

Hypoxic brain injury (ie. HIE, near drowning)

Periventricular leukomalacia (PVL)

Pervasive Developmental Disorder (PDD)

Stroke

Other

Other diagnosis

* must provide value

Patient's weight (in pounds)

* must provide value

Date Weight Obtained

* must provide value

M-D-Y

Gender

Race

* must provide value

Ethnicity

* must provide value

Insurance

Relationship

* must provide value

First Name

* must provide value

Last Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Primary Email Address

* must provide value

Confirm Email Address

* must provide value

Confirm Email Address

Email addresses do not match. Please correct.

Phone

* must provide value

Phone 2

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

* must provide value

City

* must provide value

State field will appear after Country is selected.

Country

* must provide value

State

* must provide value

State/Province

* must provide value

Zip Code

* must provide value

Add Another Contact?

Yes

reset

Contact 2

Parent, Legal Authorized Representative or Emergency Contact

First Name

Last Name

Relationship

Date of Birth

M-D-Y

Phone

Phone 2

Email Address

Same Address?

Yes

reset

Street Address

City

State field will appear after Country is selected.

Country

State

State/Province

Zip Code

Patient First Name	______
Patient Last Name (surname)	______
Patient Date of Birth	______
Patient Diagnosis	______
�	______
Primary Email Address	______

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.