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Parkinson's Disease Questionnaire
Magnolia Physical Therapy & Wellness, Inc
Questions have been adapted from the LSVT intake form.
Full Name :
*
First Name
Last Name
Birth Date :
*
Please select a month
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Month
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Day
Please select a year
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Year
Neurologist :
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Medical History
When were you diagnosed with PD ?
What were your first symptoms ?
Do you have a tremor ? If yes, describe :
Do you have any other medical issues ? If so, describe :
Do you experience on / off times ? If so, describe :
Do you experience dyskinesia ? If so, describe :
Have you had any neurosurgery ?
Tell me about any activities that you enjoy that you are not able to participate in :
What has been the most frustrating part about PD ?
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Have you experienced in the last six months :
Yes
No
Sometimes
Falls without injury
Falls with injury
Dizziness upon standing
Difficulty swallowing
Difficulty remembering or with word-finding
Pain
Walking slower
Difficulty dressing / undressing
Difficulty with handwriting
Speaking softer
Difficulty sleeping
Freezing episodes / feeling stuck
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