Application form: Parkinson's

Application form: Parkinson's
This form can be completed by the applicant, relative, friend or professional.

The application form will give the conductors an overview of your condition and how it impacts on you. Please answer as many questions as you feel able, as this will help to ensure that the initial consultation is meaningful. If you have any concerns about some questions or feel that you are not able to answer them please leave them blank.
Email
example@example.com
Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Present/previous occupation
If retired, please give year of retirement
Year of diagnosis
MEDICAL INFORMATION
Which side of your body has been more affected?
Do you have tremor?
Do you have stiffness?
Do you feel your movements have slowed?
Relevant medication - dosages and timings
Additional medical/surgical information e.g. high blood pressure, arthritis, joint replacements, accidents
Do you experience pain? If yes, where do you feel it?
On a scale to 1 to 5, how much does this pain restrict your daily activity?
IMPACT OF YOUR CONDITION
We appreciate that each day may be different and that your abilities may vary during the day, but to help us understand how your condition affects your life please answer the following questions as best you can. If you experience a wide range of ability throughout a day please try and indicate with an average score.

The questionnaire attached is an approved questionnaire for people with Parkinson’s (PDQ-39). We have chosen this as an appropriate tool to help us prepare for your consultation.
Do you experience freezing / find you suddenly stop and cannot move?
Are you prone to falling? If yes, on average how frequently do you fall?
Across your drug cycle is there any significant variation in your condition?
What elements/ symptoms of the condition do you feel are the most disabling for you?
The following questions relate to how you feel your condition has affected you and your quality of life. How often during the past month have you:

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always or cannot do
Difficulty doing leisure activities you would like to do
Difficulty looking after your home e.g. DIY, housework
Difficulty carrying bags of shopping
Problems walking half a mile
Problems walking 100yds
Problems getting around the house as easily as you would like
Difficulty getting around in public
Needed someone else to accompany you when you went out
Felt frightened or worried about falling in public
Been confined to the house more than you would like

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Difficulty washing yourself
Difficulty dressing yourself
Problems doing up buttons or shoe laces
Problems writing clearly
Difficulty cutting up food
Difficulty holding a drink without spilling it

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Felt drepressed
Felt isolated and lonely
Felt weepy or tearful
Felt angry or bitter
Felt anxious
Felt worried about the future

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Felt you had to conceal your Parkinson’s from people
Avoided situations which involve eating or drinking in public
Felt embarrassed in public places due to having Parkinson’s
Felt worried by other people’s reaction to you

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Had problems with close personal relationships
Lacked support in the ways you need from your spouse or partner
Lacked support in the way you need from family and close friends

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Unexpectedly fallen asleep during the day
Had problems concentrating e.g. when watching TV or reading
Felt your memory was bad
Had distressing dreams or hallucinations

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Had difficulty with your speech
Felt unable to communicate properly
Felt ignored by people

How often during the past month have you

Rows	Never	Occasionally	Sometimes	Often	Always
Had painful muscle cramps or spasms
Had aches and pains in your joints or body
Felt unpleasantly hot or cold

Where do you feel you are at the moment?

1

2

3

4

5

6

7

8

9

10

1 is No quality of life, 10 is Full quality of life
Could you please state where you heard about Conductive Education?
If you have attended Conductive Education in the past could you please give the dates and place.
Do youbelong to a local branch of Parkinson's UK or similar organisation? If yes, please state which.
ADDITIONAL DETAILS
Do you have access to a computer, iPad or tablet?
Which one of these services would you be interested in?
GP Details

In exceptional circumstances we may wish to contact your GP or consultant. We will NOT contact them without discussing this with you first.
Name of GP

First NameLast Name
Address of GP

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name and Hospital of Consultant
How frequently do you see your consultant?
Name of specialist nurse (if appropriate)
Any other relevant medical information you feel it is important for us to know?
I agree that I have disclosed all relevant medical information to the conductors at the National Institute of Conductive Education, Birmingham.I understand that it is my duty to inform them immediately of any relevant changes in my condition or medication and agree to do so.I agree that conductors may contact my GP or specialist should any further information be required. They will inform me of this and provide me with a copy if requested.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application form: Parkinson's

MEDICAL INFORMATION

IMPACT OF YOUR CONDITION

ADDITIONAL DETAILS

GP Details