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Parkinson’s Questionaire
Complex Care Counselling
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Parkinson’s Questionaire
Parkinsons Disease Questionnaire
Identification
First name
*
First name
*
Post Code
Date of Birth
*
GP Practice Name
*
Funding
*
Self-Paid (Start within 10 Days)
Self-Paid to Start & NHS Application
NHS Application Only (Average 12 Weeks)
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Your Situation
Your Stage
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 1
During this initial stage, the person has mild symptoms that generally do not interfere with daily activities. Tremor and other movement symptoms occur on one side of the body only. Changes in posture, walking and facial expressions occur.
Stage 2
Symptoms start getting worse. Tremor, rigidity and other movement symptoms affect both sides of the body or the midline (such as the neck and the trunk). Walking problems and poor posture may be apparent. The person is able to live alone, but daily tasks are more difficult and lengthier.
Stage 5
This is the most advanced and debilitating stage. Stiffness in the legs may make it impossible to stand or walk. The person is bedridden or confined to a wheelchair unless aided. Around-the-clock care is required for all activities.
Stage 4
At this point, symptoms are fully developed and severely disabling. The person is still able to walk and stand without assistance but may need to ambulate with a cane/walker for safety. The person needs significant help with activities of daily living and is unable to live alone.
Stage 3
Considered mid-stage, loss of balance (such as unsteadiness as the person turns or when he/she is pushed from standing) is the hallmark. Falls are more common. Motor symptoms continue to worsen. Functionally the person is somewhat restricted in his/her daily activities now but is still physically capable of leading an independent life. The disability is mild to moderate at this stage.
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Care
Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Are you in care?
No
Supportive Care
Palliative Care
Hospice Care
Other
Other
Hours
Part-time
Full-time
Live-in
Other
Other
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Next
Questions
How confident are you in making decisions for yourself?
Confident
Ok
Not Confident
Other
Other
Any Symptoms?
None
Tremor
Slowed Movement
Rigid Muscles
Impaired Posture Balance
Loss of Automatic Movements
Speech Changes
Writing Changes
Other
Other
Tremor Severity
Mild
Moderate
Severe
Other
Other
Slowed Movement Severity
Mild
Moderate
Severe
Other
Other
Rigid Muscles Severity
Mild
Moderate
Severe
Other
Other
Impaired Posture/Balance Severity
Mild
Moderate
Severe
Other
Other
Writing Changes Severity
Mild
Moderate
Severe
Other
Other
Loss of Automatic Movements Severity
Mild
Moderate
Severe
Other
Other
Speech Changes Severity
Mild
Moderate
Severe
Other
Other
Other Severity
Mild
Moderate
Severe
Other
Other
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Questionnaire
Have difficulty doing the leisure activities which you would like to do?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel isolated and lonely?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel weepy or tearful?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel angry or bitter?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel anxious?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel depressed?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel worried about your future?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel you had to conceal your Parkinson’s from people?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel embarrassed in public due to having Parkinson’s disease?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel worried by other people’s reaction to you?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have problems with your close personal relationships?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Lack support in the ways you need from your spouse or partner?
Do not have a partner or spouse
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Lack support in the ways you need from your family or close friends?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Unexpectedly fallen asleep during the day?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel your memory was bad?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have distressing dreams or hallucinations?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have aches and pains in your joints or body?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have difficulty with your speech?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel unable to communicate with people properly?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel ignored by people?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have painful muscle cramps or spasms?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Signature
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