1. The Intake Form asks questions about you and your spinal cord injury, which will help to determine if you may fit current or future Miami Project research studies.
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By checking this box and providing information about me on the intake form, I approve that I may be contacted by The Miami Project regarding current and future research studies. I do not want to share my information and do not want to be contacted by The Miami Project regarding current and future research studies.
Last name
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First name
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Gender
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Male Female
Email address
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Street address
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Country
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Phone number
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Current height - Feet
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4 5 6
Current height - Inches
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0 1 2 3 4 5 6 7 8 9 10 11 12
Current weight
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a) Less than 100 pounds b) 101-150 pounds c) 151-200 pounds d) 201-250 pounds e) More than 251 pounds
Year of birth
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1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Year your spinal cord injury occurred
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1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
What caused your spinal cord injury?
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a) Vehicular crash (car, truck, ATV, motorcycle, bicycle, boat, aircraft, etc.) b) Violence (gunshot, stab wound, hit with blunt object, explosion, etc) c) Fall (from height or level ground, trip over an object, slipping on wet surface, etc.) d) Sports (any type of sporting activity, including diving, surfing, etc.) e) Birth disorder (spina bifida, spino-cerebellar ataxia, Friedreich's ataxia, etc.) f) Infection (polio, tuberculosis, meningitis, herpes zoster, etc.) g) Tumor (spinal, vertebral) h) Auto-immune disease (Multiple sclerosis, Transverse myelitis, etc.) i) Vertebral pathology (disk herniation, spondylosis, spinal stenosis, etc.) j) Vascular (spinal stroke/infarction, AVM, hematoma, etc) k) Other-
Did you have a head injury as well?
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Yes No
Where is your spinal cord injured?
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a) Cervical 1-4 (upper neck) b) Cervical 5-8 (lower neck) c) Thoracic 1-6 (upper back) d) Thoracic 7-12 (mid back) e) Lumbar 1-5 (lower back) f) Sacral 1-5 (tail bone area/cauda equina/conus medullaris)
Do you use a ventilator or diaphragm pacer to breathe?
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Yes No
Can you feel touch sensation below your injury level?
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Yes No
Can you feel touch sensation in the anal area?
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Yes No
Can you voluntarily tighten the anal sphincter?
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Yes No
Can you feel the difference between sharp and dull below your injury level? (example: Can you feel the difference between the sharp end of a pin versus the dull end of a pin?)
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Yes No
Can you lift your LEFT arm straight up over your head?
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Yes No
Can you lift your RIGHT arm straight up over your head?
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Yes No
Can you stand up?
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a) Yes, independently b) Yes, with assistance (person or device such as a cane, walker, or electrical stimulation) c) No (only in a standing frame)
What type of assistive device do you use as your main way of moving around?
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Manual wheelchair Power wheelchair Power-assist manual wheelchair Sip and Puff wheelchair Scooter Walking device(s) None
Do you have spasticity?
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a) No b) Mild c) Moderate d) Severe
When is it problematic for you?
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Where do you have spasticity?
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How do you control your spasticity?
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Do you have pain?
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a) No b) Mild c) Moderate d) Severe
How much do you limit your activities in order to keep your pain from getting worse?
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0 - not at all 1 2 3 4 5 6 - very much 0 - not at all
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2
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5
6 - very much
How much has your pain changed your ability to take part in recreational and other social activities?
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0 - no change 1 2 3 4 5 6 - extreme change 0 - no change
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2
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5
6 - extreme change
How much has your pain changed the amount of satisfaction or enjoyment you get from family-related activities?
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0 - no change 1 2 3 4 5 6 - extreme change 0 - no change
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6 - extreme change
In general, how much has pain interfered with your day-to-day activities in the last week?
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0 - no interference 1 2 3 4 5 6 - extreme interference 0 - no interference
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4
5
6 - extreme interference
In general, how much has pain interfered with your overall mood in the past week?
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0 - no interference 1 2 3 4 5 6 - extreme interference 0 - no interference
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2
3
4
5
6 - extreme interference
In general, how much has pain interfered with your ability to get a good night's sleep?
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0 - no interference 1 2 3 4 5 6 - extreme interference 0 - no interference
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2
3
4
5
6 - extreme interference
How many different pain problems do you have?
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1 2 3 or more
Do you like to exercise?
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Yes No
Are you currently participating in an exercise program?
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Yes No
How often do you exercise each week?
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a) Less than 1 hr per week b) 1 - 3 hrs per week c) 3 - 5 hrs per week d) 5+ hrs per week
How are you exercising?
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Individual exercise for general fitness and health including arm exercise or weight lifting Recreational exercise such as wheelchair tennis, handcycling, or rugby Competitive sports such as wheelchair racing, rugby, or paralympics Electrically-stimulated cycling (RTI, TTA, or MotoMed) Passive Range of Motion Whole Body Vibration Other Individual exercise for general fitness and health including arm exercise or weight lifting
Recreational exercise such as wheelchair tennis, handcycling, or rugby
Competitive sports such as wheelchair racing, rugby, or paralympics
Electrically-stimulated cycling (RTI, TTA, or MotoMed)
Passive Range of Motion
Whole Body Vibration
Other
Can you tell when you need to empty your bladder?
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Yes No
What is the main method you use to empty your bladder?
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a) Normal (voluntary control) b) Trigger bladder reflex (ex. Tapping, scratching, anal stretch, etc.; voluntary or Involuntary) c) Manual bladder expression (abdominal straining, manual crede', valsalva manuver) d) Intermittent catheterization e) Indwelling catheter (traditional or suprapubic) f) Sacral anterior root stimulation g) Bladder diversion (augmentation, ostomy procedures, etc) h) Other
Have you had any involuntary urine leakage (accidents) during the last three months?
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a) No b) Yes, on average they occur daily c) Yes, on average they occur weekly but not every day d) Yes, on average they occur monthly, but not every week
Are you aware of when you need to have a bowel movement?
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a) No b) Yes, Normal sensations (direct) c) Yes, Indirect sensations (ex: abdominal cramping or discomfort; abdominal muscle spasms; spasms of lower extremities; sweating; goosebumps; headache; chills)
What are your normal bowel routine procedures?
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What is the average time required for completing your bowel routine?
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a) 0-5 min b) 6-10 min c) 11-20 min d) 21-30 min e) 31-60 min f) More than 60 min
How frequently do you have a bowel movement?
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a) Three times or more per day b) Twice daily c) Once daily d) Not daily but more than twice every week e) Twice every week f) Once every week g) Less than once every week, but at least once within the last four weeks h) No defecation within the last four weeks
How frequently do you have bowel accidents?
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a) Two or more episodes per day b) One episode per day c) Not every day but at least once per week d) Not every week but more than once per month e) Once per month f) Less than once per month g) Never
Do you ever need to wear a pad or plug?
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a) Daily b) Not every day but at least once per week c) Not every week but at least once per month d) Less than once per month e) Never
Have you ever had any anal problems?
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Are you able to have an erection?
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Yes No
If you can have an erection, do you need to use anything to help you maintain an erection?
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a) No help needed maintaining erection b) Yes, drugs (ex. Viagra, Levitra, Cialis, penile injections, etc.) c) Yes, devices (ex. Vibrator, penile ring, vacuum pump, penile implant, etc.) d) Yes, drugs and devices e) Cannot have erection
Are you able to ejaculate?
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Yes No
If you can ejaculate, do you need to use anything to help you?
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Are you able to have an orgasm?
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Yes No
Do bladder or bowel problems interfere with your sexual activity?
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Yes No
Have you fathered a child since your injury?
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Yes No
What method did you use?
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Natural intercourse, no vibrator "Home artificial insemination" (semen collection with a vibrator plus artificial insemination of semen into the vagina). Intrauterine insemination by a doctor In Vitro Fertilization or Intracytoplasmic Sperm Injection by a doctor Don't know/ Not sure
Do you experience vaginal arousal (lubrication) during sexual stimulation?
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Yes No
Are you able to have an orgasm?
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Yes No
Do bladder or bowel problems interfere with your sexual activity?
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Yes No
Have you given birth to a child since your injury?
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Yes No
Do you experience any sensations during your period (menses/menstruation)?
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No Yes (ex: abdominal cramping or discomfort; abdominal muscle spasms; spasms of lower extremities; sweating; goosebumps; headache; chills)
Are you a veteran?
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Yes No
Are you interested in receiving research updates from The Miami Project?
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Yes No
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