Center for Sport Brain Bank Questionnaire

Tell us more about you. (If you are pre-registering for a loved one, please provide information about the potential donor.)

Full Name:

Phone Number:

Email Address:

Date of Birth:

Gender:

Age:

Street Address:

City:

State:

ZIP code:

Have you ever played professional or collegiate sports?

If YES, what year(s) did you play:

Have you ever served in the U.S. armed forces?

If YES, are you an active member of the military or retired? If retired, what year(s) did you serve:

Have you ever been diagnosed with a disorder affecting the brain (i.e. concussion or other brain injury)?

If YES, please provide a brief explanation (including year/date of injury):

If you are a spouse, parent, or next of kin making arrangements on behalf of a potential donor, is the donor near death (within the next 7-14 days)?

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