Neurorobotics Upper-Limb Rehabilitation Studies
Thank you for your interest in the Utah NeuroRobotics Lab! This form serves to collect contact and medical information from prospective upper limb rehabilitation participants.

Please fill out to the best of your ability.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
How old are you? *
What is your gender? *
How much do you weigh? *
How tall are you? *
What is the best way to contact you? *
What is your email? *
What is your phone number? *
What day(s) are you most available? *
Required
What time(s) are you most available? *
Required
What is your earliest start date? *
MM
/
DD
/
YYYY
Where are you located? *
Can you find transportation to and from Neilsen Rehab Hospital? *
What is your primary spoken language? *
What kind of injury or condition are you recovering from?
Clear selection
What was the date of your injury (stroke, SCI, etc)?
MM
/
DD
/
YYYY
Do you suffer from hemiplegia or hemiparesis (paralysis or weakness on one side of the body)?
Clear selection
Is your injured hand partially or completely paralyzed?
Clear selection
Do you have a spastic or flaccid injured hand? (See examples)
Clear selection
What is (are) your Fugl-Meyer Score(s)? Fill out to the best of your knowledge.
What activities of daily living are you most interested in being able to do without assistance?
Do you suffer from any form of aphasia (difficulty understanding or speaking language)?
Clear selection
Confirmation *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms