BEARS Brain Donor Questionnaire
Resize font:   | 

UC Davis MIND Institute
Brain Endowment for Autism Research Sciences (BEARS) Program
24-Hour Toll Free Phone: (855) 221-HOPE (4673)
Email: mindbears@ucdavis.edu
Fax: (916) 703-0483

The BEARS Tissue Program is committed to advancing research around the world to find the causes of, develop treatments, and ultimately prevention options for neurodevelopmental disorders. All information provided on this form, as well as all of the donor's medical records, will solely be used for research purposes and kept confidential by the MIND Institute BEARS Tissue Program. We request that you complete the questionnaire as fully as possible, and return to us preferably within two months. Thank you so much for your support and involvement with the BEARS Tissue Program.

Background Information
Donor's First Name
Most Recent Address
Donor's City of Birth
Donor's State of Birth
Donor's Social Security Number
xxx-xx-xxxx
Donor's Country of Birth
Donor's Gender
Father's Name
Mother's Name & Maiden Name
Supporting Documents
Please check any of the following documents that you can either send, fax or email to us.
The donor's death certificate (if possible at this time)
The donor's birth certificate
Clinical records concerning the donor or his/her family's medical history
Information about the Person Completing this Form
Informant's Full Name
Informant's Address
City
State
Zip Code
Telephone Number
Additional Phone Number
Informant's Relationship to Donor
Next of Kin (if not informant)
Full Name of Donor's Next of Kin
Next of Kin's Address
City
State
Zip code
Phone Number
Additional Phone Number
Email Address
Personal Information on Donor
Donor's handedness
right
left
Donor's height (ft)
Donor's height (in)
Donor's weight
What hazardous substances, if any, was the donor exposed to?
Donor's Birth History
Donor's birth order
first
second
third
fourth
fifth
other
Time of day donor was born    H:M
Donor's birth weight
Please indicate any complications during the pregnancy or birth of the donor.
Difficulty in conception
In Vitro Fertilization
Measles
German Measles
Excessive swelling
Flu
Toxemia
Excessive vomiting
Emotional problems
Anemia
Abnormal weight gain
Vaginal bleeding
High blood pressure
Rh incompatibility
Labor induced with Oxytocin (ptocin)?
Prolonged labor
Prolonged delivery
Prematurity
Prolonged pregnancy
Low oxygen
Infections
Seizures
Trauma
Forceps
Breech
Jaundice
Anesthesia during delivery
Incubator
Caesarean section
APGARS during delivery
1 minute
5 minutes
10 minutes
Describe medications used during pregnancy.
prescription
non prescription
none
Indicate whether cigarettes were smoked during pregnancy.
no
yes
If cigarettes were smoked, please indicate frequency.
Indicate whether alcohol was used during pregnancy.
no
yes
If alcohol was used, please indicate frequency.
never
daily
every few days
weekly
monthly
less than once a month
Were any other substances used during pregnancy? (cocaine, marijuana, etc.)
no
yes
Donor's Medical History
Donor's doctor's name
Donor's doctor's speciality
Doctor's address
State
Zip Code
Doctor's Telephone number
Doctor's Fax number
Did the donor have any of the following medical conditions or characteristics?
Irregular or unusual body or facial features
no
yes
Provide details on the nature of the condition.
Recurrent ear infections
no
yes
Provide details on the nature of the condition.
Vision problems
no
yes
Provide details on the nature of the condition.
Difficulty sleeping
no
yes
Provide details on the nature of the condition.
Irregular response to temperature
no
yes
Provide details on the nature of the condition.
Irregular response to pain
no
yes
Provide details on the nature of the condition.
Hyperlexia (superior reading skills)
no
yes
Provide details on the nature of the condition.
Special food interest/preoccupation
no
yes
Provide details on the nature of the condition.
Allergies
no
yes
Provide details on the nature of the condition.
Enlarged head circumference
no
yes
Provide details on the nature of the condition.
Gastrointestinal problems (GERD, loose stools)
no
yes
Provide details on the nature of the condition.
Medications
Please fill out the information below or list the name and phone number of the person that we can contact to retrieve records. (You may also note, "refer to medical records" if provided.)
Please list the medication (s), approximate dates of usage, dosage, and specify whether it was effective.
Expand 
Did the donor have a history of seizures?
no
yes
What was the epilepsy diagnosis?
Year diagnosed and age of onset
Please either send, fax, or email the donor's immunization records (whichever method is easiest for you). You can also choose to provide the name and phone number of the person that we can contact to retrieve records.
Expand 
Major / Recent Medical or Psychiatric Hospitalizations. Please fill in information below or attach medical records or provide the name and phone number of the person that we can contact to retrieve records. Permission to access records may be required.
no
yes
Approximate date of hospitalization
How long was the hospitalization?
Where was the donor hospitalized and who was the donor's doctor?
Reason for admission
Information Regarding Donor's Death
What is the time of the donor's death?    H:M
What is the date of the donor's death?    M-D-Y
What was the primary cause of death?
What were the contributing causes of death, if any?
Was a complete autopsy performed?
no
yes
If yes, will you be sending, emailing, or faxing a copy of the autopsy? (You may also note, "refer to medical records" if provided.
Sending
Emailing
Faxing
Please list the name of the Coroner or Medical Examiner and County.
Additional Information for Researchers
Was the donor enrolled in any biological, genetics, or response to medication research studies? If yes, please send, email, or fax records and all data to us. You can also choose to provide the name and phone number of the person that we can contact to retrieve records.
no
yes
Name(s) of study or training program
Location of study or training program
Time frame of study or training program
Contact person to retrieve records. Please list name, phone number, and/or email.
Was the donor involved in any specific training or treatment programs, such as ABA, TEAACH, Speech or Occupational Therapy Programs? If yes, please send, fax, or email records to us, or provide the name and phone number of the person we can contact to retrieve records.
no
yes
Name of study or training program
Location of study or training program
Time frame of study or training program
Contact person to retrieve records. Please list name, phone number, and/or email.
Family History
Are/Were any of the following conditions present in the donor, donor's brother(s)/sister(s), donor's maternal relatives, and/or donor's paternal relatives? (Example: donor's maternal relatives include donor's mother, aunt, uncle, grandmother etc. on the mother's side). If yes, under "specify", list the member of the family/relative that is diagnosed with the condition. If the brother(s)/sister(s) has the condition, please indicate whether they are identical/fraternal twins or halfbrother(s)/sister(s).
Allergies
no
yes
If yes, specify.
Asthma
no
yes
If yes, specify.
Frequent ear/sinus infections
no
yes
If yes, specify.
Hearing problem
no
yes
If yes, specify.
Lupus
no
yes
If yes, specify.
Multiple Sclerosis
no
yes
If yes, specify.
Rheumatoid Arthritis
no
yes
If yes, specify.
Colitis, Irritable Bowl, Spastic Colon
no
yes
If yes, specify.
Celiac Disease
no
yes
If yes, specify.
Diabetes
no
yes
If yes, specify.
Thyroid Problems
no
yes
If yes, specify.
Immunodeficiency Problems
no
yes
If yes, specify.
Tics or Tourette Syndrome
no
yes
If yes, specify.
Epilepsy
no
yes
If yes, specify.
Autism/ASD/Asperger Syndrome
no
yes
If yes, specify.
Difficulty with Social Interaction
no
yes
If yes, specify.
Speech Problems (includes slow development in verbal skills)
no
yes
If yes, specify.
Repetitive Behavior
no
yes
If yes, specify.
Unusually Focused on Special Interests (includes portraying unusual expertise on a topic)
no
yes
If yes, specify.
Intellectual Disability/Mental Handicap
no
yes
If yes, specify.
Specific Learning Disabilities (dyslexia, dyspraxia, etc.)
no
yes
If yes, specify.
ADD/ADHD
no
yes
If yes, specify.
Attention Problems
no
yes
If yes, specify.
Heperactivity
no
yes
If yes, specify.
Impulsive Behavior
no
yes
If yes, specify.
Behavior Problems/Conduct/Disorder/Oppositional/Defiant Disorder
no
yes
If yes, specify.
Excessive Aggression
no
yes
If yes, specify.
Substance Abuse Problems
no
yes
If yes, specify.
Chemical Abuse
no
yes
If yes, specify.
Alcohol Dependency
no
yes
If yes, specify.
Mood Swings
no
yes
If yes, specify.
Depression
no
yes
If yes, specify.
Anxiety
no
yes
If yes, specify.
Obsessive Compulsive Disorder
no
yes
If yes, specify.
Psychosis
no
yes
If yes, specify.
Bipolar Disorder
no
yes
If yes, specify.
List other conditions not mentioned here.
Epidemiological Research
What is the mother's ethnicity?
White Northern European
Black African
Asian (e.g. India, Pakistan)
White Mediterranean
Afro-American
South-East Asian (e.g. China, Japan)
White East European
Caribbean
American Indian
Hispanic Spanish/Portugese
HIspanic South American
Pacific Islander
If the mother is of mixed origin or if ethnicity is not listed above, please indicate here.
Please list the mother's country of birth.
What is the father's ethnicity?
White Northern European
Black African
Asian (e.g. India, Pakistan)
White Mediterranean
Afro-American
South-East Asian (e.g. China, Japan)
White East European
Caribbean
American Indian
Hispanic Spanish/Portugese
HIspanic South American
Pacific Islander
If the father is of mixed origin or if ethnicity is not listed above, please indicate here.
Please list the father's country of birth.
How would you like to receive new research information?
Updates on our website
Updates through email
Updates through regular mail
Would you like to be in touch with other donor families within the tissue research programs network?
In your state
In the U.S. and other countries
Through a secure section of a website
How did you hear about the BEARS Tissue Program?
Costs
If you have incurred costs in addition to this brain tissue donation, please note on this page and send us receipts for reimbursement.
You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.
The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.