Online Enrollment Form

Enrollment Form

Thank you for taking the time to answer these screening questions. We ask about your health information because we want to make sure you are both safe and eligible for the study. Therefore, most of the below questions are required. You will receive an error message if you miss one.

Please note that this is a secure questionnaire that will only be available to the study coordinators, Megan Rozman and Dace Almane, and Principal Investigators, Jeffrey Binder, MD, and Beth Meyerand, PhD.

Questions

If you have any questions about the form, or if you are having trouble submitting it, please do not hesitate to call the study coordinator, Megan Rozman, at (414) 955-4485.

Consent Form

Did you read and submit the consent necessary to fill out this form?   Yes   No
If no, please go to the consent page, and read and submit it.

Background

Where did you hear about this study? 
 Flier   Friend or Family Member   Recruiter   Website Study   Other, specify: 

First Name               

Last Name 

Sex?   Male   Female

Date of Birth (dd/mm/yyyy)

Address1 

Address2 

City 

State

Zip Code 

Weight (pounds)        

Height (inches) 

Telephone number(s)  

Email  

What is the best time for us to contact you?

Specify your preferred method of communication:  

Do you speak English fluently?  Yes   No

What is your preferred study location (select one)?  Milwaukee   Madison   Either

Health and Safety

Have you been diagnosed with epilepsy by a healthcare professional?  Yes   No

Do you know what type of epilepsy you have (e.g., temporal lobe epilepsy)?  Yes   No
If yes, please describe: 

Have you ever considered yourself to be claustrophobic?  Yes   No

Do you have any metal in your body (pacemaker, plates, clips, pins, pellets, etc.)?   Yes   No
If yes, please describe: 

Are you or could you possibly be pregnant?  Yes   No

Are you seeing a doctor for a particular medical condition other than epilepsy?  Yes   No
If yes, please list: 

Have you ever been evaluated for a possible neurological disorder other than epilepsy?  Yes   No
If yes, please describe: 

Have you ever been evaluated for a possible psychological disorder?   Yes   No 
If yes, please describe: 

Have you ever had a head injury with a loss of consciousness?   Yes   No 
If yes, please describe and include the length of time you were unconscious: 

Do you wear glasses or contacts?   Yes   No 
Please check:   Glasses   Contacts   Both
If you know your prescription, please list: 

Do you now or have you ever had a vision problem that was not correctable with glasses?  Yes   No
If yes, please explain and indicate if the problem still exists: 

Do you have any hearing loss that you are aware of?  Yes   No

Do you have any body piercings with non-removable jewelry or hardware?   Yes   No

Do you have any large tattoos on your face, head, or neck?   Yes   No

Have you ever worked with metal or used welding equipment?   Yes   No

Do you wear braces, orthodontic retainers, partials or dentures?   Yes   No

 


Understanding brain networks in people with epilepsy

Jeffrey Binder, MD, Study Leader | Department of Neurology, Froedtert Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226
 

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