Parkinson's Questionnaire
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Correo *
Name *
Address *
Age *
Gender *
Contact Number *
Duration of Tremor or Shaking & Description / Remarks *
Imagen sin leyenda
Stiffness or rigidity, Please select or deselect the check boxes wherever is appropriate *
How about the patient's Postural stability? *
How about the patient's Walking difficulty? *
How about the patient's hand swing during walking ? *
How about the patient's imbalance during walking ? *
How about the patient's speech difficulties ? *
Reduced
Increased
No issues noticed
Clarity
Volume
How about the patient's memory power ? *
Total Memory loss
Slight memory loss
No issues noticed
Recent memory
Old memory
Whether patient having excessive salivation issues (Drooling)? *
Highly noticed
Slightly noticed
Occassionally
NA
While sleeping
While sitting/standing
How about following? *
Untimely
Increased
Decreased
Normal
NA
Digestion
Gastric irritation
Constipation
How about your appetite? *
How about urination habits with its frequency? *
How about your sleep.Please select deselect the check boxes wherever is appropriate *
Have ever noticed with any heaviness of head? *
Having problems during swallowing? *
Yes
No
Occassional
NA
Liquid Food
Solid food
Is your chappels slipping from your leg? *
Having Dressing difficulties? *
Can you pick small objects by hand? *
Can you hold small objects by hand? *
How about your emotional status? *
High
Occasional
Low
Controllable
NA
Mental tension
Anxiety
Sudden Anger
Emotions
Is there any issues regarding handwriting and signature? *
Legible
Illegible
Decreased size
Increased size
NA
Handwriting
Signature
Do you have bed rolling difficulties (moving and turning in bed)? *
Is there any sensory issues noticed during period of time? *
Proper sensation
Decreased sensation
Imaginary sensation
NA
Eyesight
Nose
Taste
Ear
Skin
Is there any familial history of having neurological  issues like Parkinson's Disease, Stroke, Paralysis, Dementia, Mental problems etc?   *
Any history of trauma in your head? *
Do you have epilepsy history in your lifetime? *
Have you took medications continuously for more than one year for any diseases especially for dementia, anxiety, lung disorders etc? ( If yes, please mention the condition and medicines taken) *
Do you have interactions with any chemical / poisonous / fertilizers etc?
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Any other signs and symptoms you face other than my questions?
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