Clinical Trials Volunteer Form

By completing this form, you are giving permission for the Clinical Trials department at The Parkinson’s Institute to retain your information and contact you in regards to Clinical Trials conducted at the Parkinson's Institute. The information you give us will be kept confidential in accordance with our Privacy Policy

Only fields marked with an * are required, however the more information you are able to share with us, the better we can determine your eligibility for one of our Clinical Trials.  If you do not feel comfortable completing the information on this form, please contact us directly by leaving us a voicemail at 408-542-5608 or by sending us an email to trials@thepi.org.

Please note, while this form is secure, regular email is not.  By entering an email address, you are acknowledging the unsecure nature of such communication and are giving permission for the Clinical Trials department at The Parkinson’s Institute to send information to you via email.

Your First Name *
Your Last Name *
Your City and State
Your Phone Number *
Your Email address
Your connection to Parkinson's disease *


If you are completing this form for someone else, please enter their First and Last names below.

Their First Name
Their Last Name
Their connection to Parkinson's disease *
Their City and State

Please complete the information below for the individual interested in participating in a Clinical Trial. 

Year of Birth
Month and Year of Parkinson's disease Diagnosis
Month and Year of first Parkinson's Medication

-

Current Parkinson's Medications (check all that apply)
 Not taking any PD medications  Carbidopa/Levodopa (Sinemet, Sinemet CR, Parcopa)
 Carbidopa/Levodopa/Entacapone (Stalevo, Comtan)  Selegiline (Eldepryl)
 Rasagiline (Azilect)  Ropinirole (Requip, Requip XL)
 Pramipexole (Mirapex, Mirapex ER)  Trihexyphenidyl (Artane)
 Donepezil (Aricept)  Amantadine (Symmetrel)
 Rotigotine (Neupro)  Rivastigmine (Exelon)
 Other (enter in box below):  
.

-

Previously Taken Parkinson's Medications (check all that apply)
 Never taken any PD medications  Carbidopa/Levodopa (Sinemet, Sinemet CR, Parcopa)
 Carbidopa/Levodopa/Entacapone (Stalevo, Comtan)  Selegiline (Eldepryl)
 Rasagiline (Azilect)  Ropinirole (Requip, Requip XL)
 Pramipexole (Mirapex, Mirapex ER)  Trihexyphenidyl (Artane)
 Donepezil (Aricept)  Amantadine (Symmetrel)
 Rotigotine (Neupro)  Rivastigmine (Exelon)
 Other (enter in box below):  
.

-

Current Parkinson's Symptoms (check all that apply)
 On/Off Fluctuations (See Note 1 below)  Dyskinesia (See Note 2 below)
 Hallucinations / Delusions  Pain Associated with Parkinson's Disease
 Reduced Sense of Smell  Excessive Drooling
 Orthostatic Hypotention (See Note 3 below)  GI Dysfunction (See Note 4 below)
 Changes in Memory or Thinking Ability  

Notes:

  1. Parkinson’s medication wearing off between doses 
  2. Involuntary, persistent, repetitive movement (not tremor)
  3. Drop in blood pressure when changing positions causing lightheadedness or fainting
  4. Bowel movement issues, constipation, abdominal pain, bloating, nausea, vomiting, feeling full without having eaten a lot, or weight loss

-

Please note any significant medical history (diagnoses, surgeries, etc.)

 

Please review our current Clinical Trials List. Is there a specific trial(s) you would like to participate in? 

If so, which one(s)?

.

Thank you for your interest in Clinical Trials study at the Parkinson's Institute. 

Your information will be entered into our Clinical Trials database.

If you are eligible for a current or future trial, a Clinical Trials coordinator will contact you directly.

 

To increase the security of this information please enter the displayed text in the box below 

675 Almanor Avenue | Sunnyvale, CA 94085
408.734.2800 main | 408.734.8455 fax (Main) | 408.734.9208 fax (Clinic Secure)