陸教授神經科診所帕金森病初診問卷 PD Questionnaire

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如果您是帕金森患者，以下內容是您第一次於本診所就診時，醫師會詳細詢問的資料

If you are a Parkinson's disease patient, the following information is what the doctor will ask in detail during your first visit to our clinic.

Email *

填寫日期(西元年/月/日) Date (yyyy/mm/dd) *

YYYY

填寫以下問卷者的身份是?

*如果是病人自行回答，委由他人協助勾選的話，本問卷就是由病患本人填寫

Who is filling out this questionnaire?

*If the patient is answering the questions themselves or with the assistance of others, this questionnaire is considered to be completed by the patient.

病患本人 Patient

家屬(配偶、子女) Family (spouse, children)

照顧者 Caregiver

病患姓名 Name (surname, fist name) *

出生日期(西元年/月/日) Birth date (yyyy/mm/dd) *

YYYY

您是否曾確診新冠肺炎(COVID-19)?

Have you ever been diagnosed with COVID-19?

是 YES

否 NO

若您曾經確診新冠肺炎(COVID-19)，請問確診日期(至少填寫年月，例如2021/12/01、或是2022/05)

If you have been diagnosed with COVID-19, may I know the date of diagnosis? (Please provide at least the year and month, for example, 2121/01/31 or 2022/05)

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