PD Packet (MIPS 2024)

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Are you currently in Hospice care?

NoYes

Do you have ANY of the following: Durable Power of Attorney for healthcare, Living will, and/or 'DNR' Do-Not-Resuscitate orders?

NoYes

Is it against your cultural and/or spiritual beliefs to discuss an Advanced Care Plan (Power of Attorney, Living will, 'DNR') with your medical provider?

NoYes

Which of the Following Do you Have in Place?

Durable Power of Attorney for Healthcare (Medical)Living Will"DNR" Do-Not-Resuscitate Orders

Does ANY of the following describe you: Confined to Wheelchair or Require some assistance when using Wheelchair, unable to walk, or bed ridden?

NoYes

Have you had 2 or more falls in the last year Or any fall with injury in the past year?

NoYes

Referrals: For your Parkinson’s Disease or Parkinsonism, are you currently (in the past year) doing any of the following (Check ALL that apply) ?*

Physical Therapy (PT)Speech Therapy (ST)Occupational Therapy (OT)Recreational Therapy (ex. Rock Steady Boxing; Dance/Movement Therapy; LSVT “BIG AND LOUD”; multidisciplinary rehabilitation, active music therapy, treadmill training, balance training, and "cued" exercise training; with Recreation Therapist)NONE of the Above

Primary Source of Information (please select ONE of the following):

PatientCaregiverPatient and Caregiver in Equal Proportion

PART 1 – Non-Motor Aspects

The following Six questions are above behaviors that you may or may not experience. Some questions concern common problems and some concern uncommon ones. If you have a problem in one of the areas, please choose the best response that describes how you have felt MOST OF THE TIME during the PAST WEEK. If you are not bothered by a problem, you can simply respond 'Normal'.

1.1 COGNITIVE IMPAIRMENT: Over the past week have you had problems remembering things, following conversations, paying attention, thinking clearly, or finding your way around the house or in town? (Select ONE of the following)

0: Normal: No cognitive impairment.1: Slight: Impairment appreciated by patient or caregiver with no concrete interference with the patient’s ability to carry out normal activities and social interactions.2: Mild: Clinically evident cognitive dysfunction, but only minimal interference with the patient’s ability to carry out normal activities and social interactions.3: Moderate: Cognitive deficits interfere with but do not preclude the patient’s ability to carry out normal activities and social interactions.4: Severe: Cognitive dysfunction precludes the patient’s ability to carry out normal activities and social interactions.

1.2. HALLUCINATIONS AND PSYCHOSIS: Over the past week have you seen, heard, smelled, or felt things that were not really there? (Select ONE of the following)

0: Normal: No hallucinations or psychotic behavior.1: Slight: Illusions or non-formed hallucinations, but patient recognizes them without loss of insight.2: Mild: Formed hallucinations independent of environmental stimuli. No loss of insight.3: Moderate: Formed hallucinations with loss of insight.4: Severe: Patient has delusions or paranoia.

1.3 DEPRESSED MOOD: Over the past week have you felt low, sad, hopeless, or unable to enjoy things? If yes, was this feeling for longer than one day at a time? Did it make it difficult for you carry out your usual activities or to be with people? (Select ONE of the following)

0: Normal: No depressed mood.1: Slight: Episodes of depressed mood that are notsustained for more than one day at a time. No interference with patient’sability to carry out normal activities and social interactions.2: Mild: Depressed mood that is sustained over days,but without interference with normal activities and social interactions.3: Moderate: Depressed mood that interferes with, butdoes not preclude the patient’s ability to carry out normal activities andsocial interactions.4: Severe: Depressed mood precludes patient’s abilityto carry out normal activities and social interactions.

1.4 ANXIOUS MOOD: Over the past week have you felt nervous, worried, or tense? If yes, was this feeling for longer than one day at a time? Did it make itdifficult for you to follow your usual activities or to be with other people? (SelectONE of the following)

0: Normal: No anxious feelings.1: Slight: Anxious feelings present but not sustainedfor more than one day at a time. No interference with patient’s ability tocarry out normal activities and social interactions.2: Mild: Anxious feelings are sustained over morethan one day at a time, but without interference with patient’s ability tocarry out normal activities and social interactions.3: Moderate: Anxious feelings interfere with, but donot preclude, the patient’s ability to carry out normal activities and socialinteractions.4: Severe: Anxious feelings preclude patient’sability to carry out normal activities and social interactions.

1.5 APATHY: Over the past week, have you felt indifferent to doingactivities or being with people? (SelectONE of the following)

0: Normal: No apathy.1: Slight: Apathy appreciated by patient and/orcaregiver, but no interference with daily activities and social interactions.2: Mild: Apathy interferes with isolated activitiesand social interactions.3: Moderate: Apathy interferes with most activities and social interactions.4: Severe: Passive and withdrawn, complete loss ofinitiative.

1.6 FEATURES OF DOPAMINE DYSREGULATION SYNDROME: Over the past week, have you had unusually strong urges thatare hard to control? Do you feel driven to do or think about something and findit hard to stop? [Examples such as gambling, cleaning, using the computer,taking extra medicine, obsessing about food or sex] (Select ONE of the following)

0: Normal: No problems present.1: Slight: Problems are present but usually do notcause any difficulties for the patient or family/caregiver.2: Mild: Problems are present and usually cause a fewdifficulties in the patient’s personal and family life.3: Moderate: Problems are present and usually cause alot of difficulties in the patient’s personal and family life.4: Severe: Problems are present and preclude thepatient’s ability to carry out normal activities or social interactions or tomaintain previous standards in personal and family life.

	YES	NO
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel full of energy?
4. Do you feel that your life is empty?
5. Are you in good spirits most of the time?
6. Do you often get bored?
7. Do you feel happy most of the time?
8. Do you prefer to stay at home, rather than going out and doing new things?
9. Do you think it is wonderful to be alive now?
10. Are you afraid that something bad is going to happen to you?
11. Do you often feel helpless?
12. Do you think that most people are better off than you are?
13. Do you feel you have more problems with memory than most?
14. Do you feel pretty worthless the way you are now?
15. Do you feel that your situation is hopeless?

Form: PD PACKET

This can be filled out by the patient or a care partner. This helps us better understand your current medical condition and how we can provide the best care to you.

GDS (Short Form)

The Parkinson Anxiety Scale (PAS)