You have expressed interest in participating in the PARK MoVR study, which aims to explore perceptions of people with Parkinson's disease to immersive VR environments exercise interventions. To determine if you are eligible for this research study we need to ask you some prescreening questions about your medical history, and some of these will be of a personal nature. These questions should take less than 15 minutes.
There is a risk of a loss of confidentiality or privacy, however, this risk is minimized by storing your data in secured databases at Virginia Commonwealth University, with access limited to study personnel and individuals authorized to access data for the purposes of monitoring research.
Participation in this survey is voluntary, and you do not have to answer any question you do not want to answer and you may choose to stop the survey at any time. Choosing not to participate or withdrawing from the survey will result in no penalty or loss of benefits to which you are otherwise entitled.
Based on your answers to these questions we will determine if we can schedule you for a demonstration appointment. However, if based on your answers to these questions we determine that you are not eligible for the study, we will only record data that cannot be linked to you personally, but we will keep a record of your answers so that we can obtain a better understanding about the local population of people with Parkinson's disease. In the future, identifiers might be removed from the information you provide in this survey, and after that removal, the information could be used for other research studies by this study team or another researcher without asking you for additional consent. You will not benefit directly from completing this screening survey, and we do not have plans to return individual results from this survey to you.
As part of this research, we will ask you to share identifiable health information with us and/or permit us to access existing information from your healthcare records. New health information may also be created from study-related tests, procedures, visits, and/or questionnaires. This type of information is considered "Protected Health Information" that is protected by federal law.
The following types of information may be used for the conduct of this research: medical history
VCU and VCU Health are required by law to protect your identifiable health information. By consenting to this study, you authorize VCU/VCU Health to use and/or share your health information for this research. The health information listed above may be used by and/or shared with the following people and groups to conduct, monitor, and oversee the research: Principal Investigator and Research Staff, Health Care Providers at VCU Health, Institutional Review Boards, Government/Health Agencies, and others as required by law.
Once your health information has been disclosed to anyone outside of this study, the information may no longer be protected under this authorization. This authorization will expire when the research study is closed, or there is no need to review, analyze and consider the data generated by the research project, whichever is later.
You may change your mind and revoke (take back) the right to use your protected health information at any time. However, even if you revoke this authorization, the researchers may still use or disclose health information they have already collected about you for this study. If you revoke this Authorization, you may no longer be allowed to participate in the research study. To revoke this Authorization, you must write to the Principal Investigator at:
900 E Leigh St, Floor 4, BOX 980224, Richmond, VA 23298.
The investigator named below is the best person to contact if you have any questions, complaints, or concerns about your participation in this research:
James Thomas, DPT, Ph.D.
1200 E Broad St, RM B-104b
Box 980224
Richmond, VA 23298
Jthomas32@vcu.edu
If you have general questions about your rights as a participant in this or any other research, or if you wish to discuss problems, concerns or questions, to obtain information, or to offer input about research, you may contact:
Virginia Commonwealth University Office of Research
800 East Leigh Street, Suite 3000, Box 980568, Richmond, VA 23298
(804) 827-2157; https://research.vcu.edu/human_research/volunteers.htm
Do you consent to answer these questions?
* must provide value
Yes
No
First Name
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Last Name:
* must provide value
Today's date
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Today Y-M-D Format: Year-Month-Day
You have answered "No" meaning you decline consent to answer the prescreening questions. You will need to consent to answer the prescreening questions if you wish to complete this screening questionnaire.
We are sorry you do not wish to answer the prescreening questions for the PARK MoVR study. Please recommend our study to others you feel would be interested. Researchers at Virginia Commonwealth University is exploring many different areas of exercise rehabilitation for people with Parkinson's Disease. We would be happy to discuss the PARK MoVR study with you further. You may contact us at MCL@vcu.edu.
Are you 18 years of age or older?
* must provide value
Yes
No
Have you been diagnosed with Parkinson's Disease?
Yes
No
You have indicated you are NOT at least 18 years of age. If you are NOT 18 you may not legally consent to answer the prescreen questions or participate in our study. We welcome you to inquire about the PARK MoVR study again when you are 18 years of age or older. Thank you.
Please provide your initials:
(Example: John Paul Smith = JPS)
* must provide value
Email address
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Phone
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Date of birth
* must provide value
Today Y-M-D Format: Year-Month-Day
Sex assigned at birth
* must provide value
Male
Female
Intersex or Indeterminate
What is your approximate height?
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4-feet 4-feet 1-inch 4-feet 2-inch 4-feet 3-inch 4-feet 4-inch 4-feet 5-inch 4-feet 6-inch 4-feet 7-inch 4-feet 8-inch 4-feet 9-inch 4-feet 10-inch 4-feet 11-inch 5-feet 5-feet 1-inch 5-feet 2-inch 5-feet 3-inch 5-feet 4-inch 5-feet 5-inch 5-feet 6-inch 5-feet 7-inch 5-feet 8-inch 5-feet 9-inch 5-feet 10-inch 5-feet 11-inch 6-feet 6-feet 1-inch 6-feet 2-inch 6-feet 3-inch 6-feet 4-inch 6-feet 5-inch 6-feet 6-inch 6-feet 7-inch 6-feet 8-inch 6-feet 9-inch 6-feet 10-inch 6-feet 11-inch 7-feet 7-feet 1-inch 7-feet 2-inch 7-feet 3-inch 7-feet 4-inch 7-feet 5-inch 7-feet 6-inch 7-feet 7-inch 7-feet 8-inch 7-feet 9-inch 7-feet 10-inch 7-feet 11-inch
What is your approximate weight? (pounds)
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What is the race with which you most closely identify? (Select all that apply)
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What is the ethnicity with which you most closely identify?
* must provide value
Hispanic or Latino
Not Hispanic or Latino
How did you hear about the PARK MoVR study?
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If other, please describe:
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Directions: Please read each of the following statements and select the answer that best represents your feelings.
Have you had any of the following cardiorespiratory conditions?
Congestive heart failure
Heart attack in the last 2 years
* must provide value
Yes
No
Have you had any of the following neurological conditions?
Multiple Sclerosis
Stroke Osteonecrosis
Alzheimer's Disease
Amyotrophic Lateral Sclerosis
Seizure
* must provide value
Yes
No
Do you have a personal history of any of the following musculoskeletal disorders?
Rheumatoid Arthritis
Muscular Dystrophy
Pathologic fractures of the spine
Avascular Necrosis or Osteonecrosis
Severe Osteoarthritis
* must provide value
Yes
No
Have you ever had spinal surgery or hip arthroplasty?
* must provide value
Yes
No
Do you currently...?
...have a significant visual impairment that would prevent virtual reality headset use?
...have a disorder (not related to PD) impairing gait, stance, balance or coordination?
...wear braces or orthotics that assist with walking?
...have a personal history of peripheral neuropathy?
...have a personal history of implantable cardiac device or ablative surgery
...have a chronic disease that may restrict movement or preclude safe participation?
* must provide value
Yes
No
Are you currently...?
...Blind?
...Pregnant (or anticipate becoming pregnant in the next 2-months)?
...Lactating?
...Diagnosed with active cancer?
Yes
No
Yes
No
Please inform the research staff so that they can make arrangements within the game to personalize your experience.
Over the past 10-years have you been nauseated or vomited due to the following activities?
Driving, or being driven in a car or bus/coach?
* must provide value
Never
Rarely
Sometimes
Frequently
Always
While on a boat?
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Never
Rarely
Sometimes
Frequently
Always
While on a roller coasters or similar ride?
* must provide value
Never
Rarely
Sometimes
Frequently
Always