DEBUSSY trial


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Deep Brain Stimulation for Spasmodic Dysphonia: DEBUSSY trial - Screening Form

February 16, 2016 Dear Patient, We are screening potential patients to enter our DEBUSSY trial to evaluate the benefits of deep brain stimulation on the vocal dysfunction of spasmodic dysphonia. If you are interested in potentially being involved in this clinical trial, please fill in the form below and then mail or email it to our study coordinator. Email: [email protected] Mail: Dr. C.R. Honey, Suite 8105, 2775 Laurel St., Vancouver, BC, V5Z 1M9 Thank you for your consideration. Sincerely,

Christopher R. Honey MD, DPhil, FRCSC Professor of Neurosurgery, UBC

DEBUSSY Trial

Screening Form 1.0 February 16, 2016

1) Do you have adductor or abductor or mixed spasmodic dysphonia?

□Not Sure

□Adductor

□Abductor

□Mixed

2) Do you have essential voice tremor or muscle tension dysphonia or any other voice disorder?

□Not Sure

□Yes

□No

3) Have you had brain surgery in the past?

□Not Sure

□Yes

□No

4) Have you had laryngeal denervation-reinnervation surgery in the past?

□Not Sure

□Yes

□No

5) Are you being treated for Parkinson’s disease, Alzheimer’s disease, or any other neurodegenerative disorder?

□Not Sure

□Yes

□No

6) Have you ever had a stroke or multiple sclerosis?

□Not Sure

□Yes

□No

7) Have you ever had a cardiac (heart) pacemaker or heart attack?

□Not Sure

□Yes

□No

8) Are you currently taking blood thinners or being treated for any bleeding disorder?

□Not Sure

□Yes

□No

9) Do you have cancer or any other serious medical problems?

□Not Sure

□Yes

□No