Brain Donors

Enrolment Form

Thank you for you enquiry regarding becoming a brain donor with our program. In order to proceed with your enquiry, could you please respond to the following questions. We are currently only able to enrol donors from NSW, ACT, VIC, QLD, SA, WA and NT. Due to our exclusion criteria we are unable to accept donations from anyone suffering an infectious disorder such as Hepatitis B and C, HIV and AIDS and Creutzfeldt-Jakob disease.

The answers to these questions will be held in the strictest confidence, and destroyed if you decide not to proceed.

Full Name:	DOB:
Male Female
Address: Postcode:	Email: Country:
Phone: (h)	(m)
Preferred contact method: Phone (h) Phone (m) Email
Are you an Australian resident or citizen?	Yes No
Are you a whole body donor? (this is where you have agreed, usually with a university, to donate your entire body to research- NOT organ donation)	Yes No
Have you ever been diagnosed with: (if yes, please provide details)
An infectious disease such as Hepatitis, HIV, AIDS, CJD?	Yes No Details:
Have you ever suffered from a head injury with loss of consciousness?	Yes No Details:
Have you ever suffered from a stroke?	Yes No Details:
Have you ever suffered from a brain tumour?	Yes No
Have you ever suffered from epilepsy?	Yes No Details:
Have you ever used recreational/illicit drugs?	Yes No Details:
A mental illness?	Yes No Details:
Dementia or Alzhiemer's Disease?	Yes No
Parkinson's Disease?	Yes No
Multiple Sclerosis?	Yes No
Motor Neurone Disease?	Yes No
Other neurological disorder?	Yes No Details:
Do you have any other major health problems?	Yes No Details:
Please list the name and dosage of any medications you take on a regular basis:	Details:
How did you hear about 'Using our Brains'?	Details: