Initial Enrollment Checklist
File #: ______________
Date: ____________
VLSM Project:
1) Obtain consent with Current VA/UCB Consent Form
2) Give copy of Consent Form to Participant
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3) Preferences for Contact Information:
a. Primary Phone: ____________________________
b. Alternate Phone: __________________________
c. Preferred Mailing Address: ___________________________________
____________________________________
4) Medical Events Questionnaire
Pertaining to Event: __________________________________
a. Entered in Database
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5) Initial Assessments:
a. ASCAN Test & Visual Field Confrontation
i. Scored, Entered in Database,
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ii. Submitted to Lab Manager for 2nd Scoring, creation of file, assigning someone
to 2nd score and write patient initials & ID number on each ASCAN page
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b. Psychophysics/Staircases
i. Feature Search (date: _____________)
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ii. Conjunction Search (date: _____________)
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iii. fRACT Visual Acuity Date: _______ logMar: _______ Snellen: ____/____
iv. Entered in Database & Logfiles Uploaded
6)
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Refer for Individualized Testing
a. Krista Parker /Reference Frames / Object/Location Task
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b. Francesca Fortenbaugh/ Spatial Distortions / Landmark Task
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c. Allison Connell / Multimodal Neglect
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d. Allie, Bryan / Imaginal-Representational Neglect
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e. ________________________________________
If Participant is 3+ months Post-Injury(or more):
1) Is patient willing to undergo an MRI for research purposes?
2) Preferred Location?
UCB
YES
NO
VA
a. MRI Questionnaire/Screening Form
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b. Get Patient Info/Screening to Krista for Scheduling
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c. Visit Scheduled for: ______________________
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If Participant is LESS than 12 months Post-Injury:
What i is the 1-yr Post Injury Date ? _________________________
Is Participant willing to be contacted for 1-yr Follow-up Testing?
YES
or
NO
**If “NO” Answer is recorded above, Change Subject’s Status in Database to “INACTIVE”
If Participant is 12 months Post-Injury or More:
Would Participant like to be referred to Dr. Nina Dronkers Stroke Program where they will learn more
about how speech & language are affected by Stroke?
YES
or
NO
**After Info has been Entered/Updated in Database, Turn this Checklist into the Lab Manager!
7) Compensated ________
Date: __________
Initialed by:
________
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8) Compensated ________
Date: __________
Initialed by:
________
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9) Compensated ________
Date: __________
Initialed by:
________
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10) Compensated ________
Date: __________
Initialed by:
________
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11) Compensated ________
Date: __________
Initialed by:
________
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(Last Updated: 06/21/11)
MEDICAL EVENTS QUESTIONNAIRE
Now I would like to ask you some questions about your recent medical history and
current health status. All of this information will be kept confidential and is being
collected strictly for research purposes. Please answer as accurately as possible. If a
particular question makes you uncomfortable, you may decline to answer.
1) Our records indicate that you had/underwent ______________________________
on ___________________ (Date). Does this seem accurate to you? Do you remember this
experience/episode?
2) After you were treated for the above ________________________(event) and discharged
from the hospital, did you have any subsequent complications or problems that you
thought were related? If so, can you describe these problems/complications to me now?
a. Did you see a medical doctor for any of these complications/problems?
__________
b. Do you continue to experience any of these problems/symptoms now? If so, can
you elaborate?
3) Since the aforementioned (event), have you been medically treated for any other
neurological or sensory changes? [Prompt as needed: This could include changes in vision,
changes in your hearing, changes in your ability to speak, difficulties remembering things. It could
also include strokes, seizures, loss of consciousness, or brain surgery. Have you had any
falls/accidents? Any head injury?]
4) Do you have any history of (how recent/how many yrs, items in bold require further
questioning due to possible exclusionary status):
a. Diabetes?
b. Radiation treatment or Chemotherapy? Where? How recently?
c. Seizures? How often? How many years? Medication?
d. Brain tumor or aneurysm?
e. Hypertension (high blood pressure)?
5) Have you undergone any surgeries since we last met with you in ____________(date)?
[Cataracts? Heart? Brain surgery?]
6) Are you feeling reasonably healthy today?
7) What types/names of medications are you currently or regularly taking?
Visual Field Testing
File No: ____________
Date: _______________
Instructions: Now I’d like you to cover one eye with the palm of your hand/occluder, and with the
other eye – look at my nose and keep looking at my nose at all times.
When you see my fingers come into your field of view, tell me whether you see 1 or 2
fingers.
Documentation: Please shade regions of impaired vision for each eye (from the patient’s point of
view). Example, Left Hemianopsia would be indicated by shading on the left side of
each grid below.
Left Eye
Right Eye
Circle, if appropriate:
Full Fields
Hemianopsia
Quadranopsia
L/R
Upper / Lower
If none of the above, or test was otherwise problematic/compromised, please note below:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Color Vision Deficit:
Self report:
Yes
No
Test result:
Yes
No
Comments:
__________________________________________________________________________________
__________________________________________________________________________________