Brain Tissue Donation Questionnaire
› This form must be completed by the family and sent to the Brain Bank ahead of time. Please mail, email, or fax this form to:
Date of completion: _________________________
Rachel LaPaille-Harwood Mayo Clinic Neuropathology Program Coordinator 4500 San Pablo Road Birdsall Building, Room 310 Jacksonville, FL 32224 Email: lapaille-harwood. rachel @ mayo. edu Phone: 904-953-2439 Fax: 904-953-7117
Name of patient: _____________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ City: _______________________________________ State / Province: ______ ZIP code: ____________ Country: __________ Phone: ______________________________________________ Email: ________________________________________________
Name of next of kin: ________________________________________________________________________________________ Relationship to patient: ______________________________________________________________________________________ Address of next of kin: _______________________________________________________________________________________ City: _______________________________________ State / Province: ______ ZIP code: ____________ Country: __________ Phone: ______________________________________________ Email: ________________________________________________
9
Patient’ s date of birth: ___________________________ Sex assigned at birth: q Female q Male
Preferred gender pronoun( s) to use: _____________ Race: q Asian q Black or African American q Hawaiian or Other Pacific Islander q Native American, Indigenous, or Alaska Native q White q Other Ethnicity: q Of Hispanic, Latino, or Spanish Origin q Not of Hispanic, Latino, or Spanish Origin
Current neurological diagnosis: q Progressive supranuclear palsy( PSP) q Corticobasal degeneration / syndrome( CBD / CBS) q Multiple system atrophy( MSA) q Frontotemporal dementia with parkinsonism( FTDP) q Other: _____________________________________________
Year of diagnosis: _____________________________________ Year of symptoms onset: ______________________________ What were the patient’ s early symptoms, in the first year before / of diagnosis? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________