PD Packet (MIPS 2024)

  • Form: PD PACKET

    (Parkinson's and other Parkinsonisms Screening) [MIPS 2025]

  • 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.

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Are you currently in Hospice care?
  • ADVANCE CARE PLAN: Do you have ANY of the following: Durable Power of Attorney for healthcare, Living will, and/or 'DNR' Do-Not-Resuscitate orders?
  • 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?
  • Which of the Following Do you Have in Place?
  • Does ANY of the following describe you: Confined to Wheelchair or Require some assistance when using Wheelchair, unable to walk, or bed ridden?
  • Have you had 2 or more falls in the last year Or any fall with injury in the past year?
  • Referrals: For your Parkinson’s Disease or Parkinsonism, are you currently (in the past year) doing any of the following (Check ALL that apply) ?
  • Primary Source of Information (please select ONE of the following):

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

  • GDS (Short Form)

    Instructions: Choose the best answer for how you felt over the past week.

  • Rows

  • The Parkinson Anxiety Scale (PAS)

  • A. Persistent Anxiety

    Please mark one circle for each item below.

     

    In the past Four weeks, to what extent did you expirence the following symptoms?

  • A.1. Feeling anxious or nervous
  • A.2. Feeling tense or stressed
  • A.3. Being unable to relax
  • A.4. Excessive worrying about everyday matters
  • A.5. Fear of something bad, or even the worst, happening

  • B. Episodic anxiety

    Please mark one circle for each item below.

     

    In the past Four weeks, to what extent did you expirence episodes of the following symptoms?

  • B1. Panic or intense fear
  • B2. Shortness of breath
  • B3. Heart palpitations or heart beating fast (not related to physical effort or activity)
  • B4. Fear of losing control

  • C. Avoidance behavior

    Please mark one circle for each item below.

     

    In the past Four weeks, to what extent did you fear of avoid the following situations?

  • C.1. Social situations (where one may be observed, or evaluated by others, such as speaking in public, or talking to unknown people)
  • C.2. Public settings (situations from which it may be difficult or embarrassing to escape, such as queues or lines, crowds, bridges, or public transportation)
  • C.3. Specific objects or situations (such as flying,heights, spiders or other animals, needles, or blood)
  • Should be Empty: