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Parkinson's Disease: Symptoms and Treatment Monitoring (continuously updated) Health

Parkinson's Disease patient records: Symptom and Treatment Monitoring  

Individuals prone to Parkinson’s Disease prevention methods and progress/monitoring

Field name

Field description

pseudo-identity

 

Age

 

Current Treatment for Parkinson's

 

Hoen and Yahr

Please select your Parkinson's status according to the following Hoehn and Yahr Scale:

Please note, for this question bilateral means both sides. Symptoms can be different on each side). • Unilateral involvement only, usually with minimal or no functional disability

• Bilateral or midline involvement without impairment of balance

• Bilateral disease: mild to moderate disability with impaired postural reflexes; physically independent • Severely disabling disease; still able to walk or stand unassisted

• Confinement to bed or wheelchair unless aided

Year of Birth

 

Country of Origin

 

Ethnic Background

 

Current Country of Residence

 

Marital Status

 

Education

 

Work Status

 

Height

 

Weight

 

Year of Parkinson’s diagnosis

 

Stage of Parkinson’s

 

DBS implantation surgery

 

Date of DBS implantation surgery

 

Medical treatment for Parkinson's

 

Medication 1

 

 

Medication 2

 

 

Medication 3

 

 

Medication 4

 

 

Medication 5

* If your medication contains more than one active component, please indicate the component dose in the parenthesis.

For example: if you take Duodopa (the Levodopa dose) - inticate the Levodopa dose.

Are you taking any other Parkinson's medication?

Please list medication, dose in each serving, unit, times a day and total daily dose:

How many types of medication do you take to treat Parkinson's?

 

Medication 1

 

 

Medication 2

 

 

Medication 3

 

 

Medication 4

Select medication list Type \ Prolong-release Serving dose Unit Times a day Total daily dose (Milligram)

Have you started taking Mannitol?

 

Please select your Parkinson's status according to the following Hoehn and Yahr Scale:

(Please note, for this question bilateral means both sides. Symptoms can be different on each side).

 

Unilateral involvement only, usually with minimal or no functional disability

 

Bilateral or midline involvement without impairment of balance

 

Bilateral disease: mild to moderate disability with impaired postural reflexes; physically independent

 

Severely disabling disease; still able to walk or stand unassisted

 

Confinement to bed or wheelchair unless aided

For how many years approximately are you in this current status?

 

Below are questions concerning the symptoms you are experiencing.

Please select the answer that best applies to your current condition:

Posture

 

Normal posture

 

Slightly to mildly stooped, may lean to one side with ability to correct

 

Severely stooped with kyphosis without the ability to correct posture

 

Extreme abnormality of posture

Handwriting


Normal, no change

 

Slightly smaller or slower than usual, some words are illegible

 

Smaller or slower than usual, most words are illegible

 

Illegible handwriting

Night sleep

How many hours do you sleep

CONTINUOUSLY?

Night sleep

How many hours do you sleep

IN TOTAL?

Facial expression

 



Normal facial expression

 

Slight "masked/ poker face"

 

Loss of expression (lips parted most of the time)

 

Other

Chronic constipation

No constipation

 

Slightly suffer, not disturbing my daily activities

 

Moderately suffer, disturbing my daily activities

 

Severe, need external aid to empty my bowels


 

Hallucinations

 

No hallucinations

 

Rarely suffer from hallucinations

 

Often suffer from hallucinations

 

Suffer from hallucinations on a daily basis

Motor activities-

Please rank both frequency and severity for each symptom according to the following scale:

Frequency     

1: Never                        

2: Infrequently

3: frequently                

4: All the time  

Motor activities-

Please rank both frequency and severity for each symptom according to the following scale:

Severity

1: Normal

2: Slightly suffer yet functioning

3: Moderately suffer yet functioning

4: Unbearable - dysfunction

Freezing of gait

* Stuttering Backwards

* No arm swing while walking

* Gait abnormality

* Muscle cramps

* Freeze (not facial expression)

* Difficulty dressing

* Getting out of bed\ chair by yourself

* Pain

* Urgent urination

 

Freezing of gait

* Stuttering Backwards

* No arm swing while walking

* Gait abnormality

* Muscle cramps

* Freeze (not facial expression)

* Difficulty dressing

* Getting out of bed\ chair by yourself

* Pain

* Urgent urination

Frequency 1-4

Freezing of gait

* Stuttering Backwards

* No arm swing while walking

* Gait abnormality

* Muscle cramps

* Freeze (not facial expression)

* Difficulty dressing

* Getting out of bed\ chair by yourself

* Pain

* Urgent urination

Severity 1-4

Have you lost your sense of smell?

 

Have you suffered from falls related to Parkinson's?

 
   

Tremor -

Please rank both frequency and severity only for your relevant body part,

according to the following scale:

 

*Right side (hand only)

 

Right side (leg only)

 

Right side (hand and leg)

 

Left side (hand only)

 

Left side (leg only)

 

Left side (hand and leg)

 

Neck/ head

 

Entire body

Tremor -

Please rank both frequency and severity only for your relevant body part,

according to the following scale:

Frequency                            

1: Infrequently tremor

2: Frequently tremor               

3: Tremor all the time    

        

Severity  

1: Slightly suffer yet functioning

2: Moderately suffer yet functioning

3: Unbearable - dysfunction



Daily activities -

Please rank both frequency and severity for each symptom according to the following scale:

Frequency     

1: Never                        

2: Infrequently (not every day)

3: frequently (every day, but not all the time)              

4: All the time    

Severity

1: Normal

2: Slightly suffer yet functioning

3: Moderately suffer yet functioning

4: Unbearable - dysfunction  

* Vocal intensity decline

* Difficulty understanding my speech

* Difficulty in typing

* Memory problems

* Fatigue

* Lack of appetite

* Eating tasks difficulty

* Difficulty in swallowing

* Drooling

* Difficulty brushing teeth

Frequency     

1: Never                        

2: Infrequently (not every day)

3: frequently (every day, but not all the time)              

4: All the time    

* Vocal intensity decline

* Difficulty understanding my speech

* Difficulty in typing

* Memory problems

* Fatigue

* Lack of appetite

* Eating tasks difficulty

* Difficulty in swallowing

* Drooling

* Difficulty brushing teeth

Severity  

1: Slightly suffer yet functioning

2: Moderately suffer yet functioning

3: Unbearable - dysfunction

 


Rigidity -


Please select your rigid joints:


(Select only those that apply, no need to select all)

Color coding- diagram

Mental, behavior and mood -


* Physically independent

* Motivation and Initiative

* Maintaining normal mood

* Energy and vitality level

* Maintaining family life

* Maintaining social life

* Maintaining quality of life in general

Please grade your condition in the following:

Normal Reasonable Difficult Very difficult Unbearable Irrelevant

Additional symptoms -

In case you suffer from symptoms that were not mentioned in this registry, please detail:

 

Do you suffer from additional conditions/ diseases (Select all that apply)?

 

I don't suffer from additional conditions/ diseases

 

Yes, hypertension

 

Yes, hypotension

 

Yes, diabetes

 

Other


MEDICATION FOR ADDITIONAL DISEASES (If not applicable, skip this question by clicking "Next" button).


If you are taking medication that is not related to Parkinson's, please list in the table below (you can list up to 6):




* If your medication contains more than one active component, please indicate the highest dose component

Type in disease name Type in medication name Total daily dose

(in Milligrams)


medication 1




medication 2




medication 3




medication 4




medication 5

What are your diet habits?

Omnivore

 

Vegetarian

 

Vegan

 

Other

Do you consume any food supplements?

 

Please list your weekly exercise activity?

You can choose more than one answer

 

No exercise

 

Swimming

 

Rowing

 

Jogging

 

Biking

 

Dancing

 

Tai Chi

 

Pilates

 

Walking

 

Other

How many times a week do you exercise?

 

Are you assisted by an alternative treatment such as acupuncture, reflexology etc.?

 

Any comment or additional insight is appreciated:

 

Cannabis treatment

y/n frequency

Additional refinement available

 
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