Skip to content
Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Menu
Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Menu
Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Call Us Now
Parkinson's Disease Questionnaire
Parkinson's Disease Questionnaire
Questions have been adapted from the LSVT intake form.
First Name
Last Name
Birth Date
Neurologist
Medical History
When were you diagnosed with PD ?
What were your first symptoms ?
Do you have a tremor ? If yes, describe
Do you have any other medical issues ? If so, describe
Do you experience on / off times ? If so, describe
Do you experience dyskinesia ? If so, describe
Have you had any neurosurgery
Tell me about any activities that you enjoy that you are not able to participate in
What has been the most frustrating part about PD
Have you experienced in the last six months
Falls without injury
Yes
No
Sometimes
Falls with injury
Yes
No
Sometimes
Dizziness upon standing
Yes
No
Sometimes
Difficulty swallowing
Yes
No
Sometimes
Difficulty remembering or with word-finding
Yes
No
Sometimes
Pain
Yes
No
Sometimes
Walking slower
Yes
No
Sometimes
Difficulty dressing / undressing
Yes
No
Sometimes
Difficulty with handwriting
Yes
No
Sometimes
Speaking softer
Yes
No
Sometimes
Difficulty sleeping
Yes
No
Sometimes
Freezing episodes / feeling stuck
Yes
No
Sometimes
Submit
