PBH New Participant Questionnaire 810.02

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Getting To Know You!

Email *

First Name *

Last Name *

ADDRESS: Street, City, State, Zip *

Where did you hear about PBH? *

Which online group do you wish to participate in?

Women/Wives whose husbands have been DIAGNOSED with Parkinson's

Men/husbands whose wive's have been DIAGNOSED with Parkinson's

LGBT Care Partners of Those With Parkinson's

Young Adult of People with Parkinson's (21 & Over, Married)

Young Adults Of Parent with Parkinson's (Ages 17 - 20)

Teens of Parent with Parkinson's (Ages 13 - 16)

LBGT Family and Friends

Parent of Adult Child with Parkinson's

I only want to gain knowledge on how PD impacts those with it, their caregivers and society in general. I DO NOT feel I have Parkinson's nor have I been DIAGNOSED with Parkinson's.

Other:

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Your Role *

Care Partner (PWP is fully capable of self care)

Caregiver (You are fully active in PWP care & are now the "responsible one" in the relationship)

Essential Caregiver (You "do it all" due to PwP is in stage 3/4 of Parkinson's)

The PWP is in a longterm care facility

Widowed

Family Member

Friend

Just looking to learn

I have been diagnosed with Parkinson's

I feel I might have Parkinson's

Other

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