Images of Parkinson’s disease III

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Pour la version francaise cliquer ici:

Für die deutsche Version klicken Sie bitte hier:

This questionnaire is meant for people diagnosed with (idiopathic) Parkinson’s disease and those with parkinsonian symptoms with a diagnosis of parkinsonism.

The questions in this survey have been selected from symptoms and complaints of Dutch parkinson patients. Every patient seems to have a different set of complaints and not every complaint is a symptom of Parkinson’s disease. By filling in as many questions as you can, you help us to complete the picture. This questionnaire is designed with the purpose to give the respondent an understanding of the meaning behind the questions. The answers should always be such that a high score is associated with a high degree of complaint. The basic meaning of the answers is the following:
1 = absent
2 = hinder or pose a problem
3 = moderate impact
4 = present, very bothersome
5 = present, makes daily routine impossible

It takes about 15 minutes to fill in this form.
Dont forget to push the button "Send data" when you are finished.
After six months you will be contacted by e-mail to fill in this form once more.

Joop Oele, 2-1-2004, 1-12-2005, 19-9-2006.


Personal data

Name


E-mail address
(necessary to send information and to compare results)

Country

Gender male female

Date of birth

What were you diagnosed with?
No parkinsonian features
I was diagnosed with Parkinson’s disease
I was diagnosed with MSA
I was diagnosed with PSP
I was diagnosed with Restless Legs Syndrome
I was diagnosed with unspecified Parkinsonian features

What is the date of your diagnosis?

Mental Welbeing
Are you often depressed? 1 2 3 4 5
Is it hard for you to deal with stress? 1 2 3 4 5
Are you often forgetting things? 1 2 3 4 5
Is it hard for you to organize your thoughts? 1 2 3 4 5
Is it often hard for you to find a specific word? 1 2 3 4 5
Is it hard for you to formulate a correct sentence? 1 2 3 4 5
How hard is it for you to handle a conflict situation? 1 2 3 4 5
Do you have trouble planning things? 1 2 3 4 5
Is it hard for you to make a decision? 1 2 3 4 5
Is it hard for you to initiate anything? 1 2 3 4 5
Do you have problems performing multiple tasks? 1 2 3 4 5
Are you afraid of becoming socially isolated? 1 2 3 4 5
Do you have difficulty falling asleep? 1 2 3 4 5
Do you often wake up during the night? 1 2 3 4 5
Do you frequently not get enough sleep in 24 hours? 1 2 3 4 5
Is it sometimes hard for you to stay awake? 1 2 3 4 5
Do you have vivid dreams with a lot of body movements? 1 2 3 4 5
Are you often irritable or unreasonable, or do you suffer from mood swings? 1 2 3 4 5
Is it hard for you to concentrate? 1 2 3 4 5
Do you suffer from hallucinations? 1 2 3 4 5


General condition of the Body
Could your movements be called “slow”? 1 2 3 4 5
Do you have dyskinesias? 1 2 3 4 5
Do you react well to levodopa (Sinemet/Madopar/Stalevo)? 1 2 3 4 5
Do you often have a tingling sensation in the hands, legs, arms or face? 1 2 3 4 5
Is it hard for you to walk? 1 2 3 4 5
Is it hard for you to keep walking for a longer period? 1 2 3 4 5
Do you often feel exhausted? 1 2 3 4 5
Are you very rigid after a night’s sleep? 1 2 3 4 5
Do you often have muscle pains? 1 2 3 4 5
Do you suffer from loss of muscle power? 1 2 3 4 5
Do you recover slowly from physical exertion? 1 2 3 4 5
Do you have balance problems? 1 2 3 4 5
Do you have diminished spatial sense (impaired proprioception)? 1 2 3 4 5
Are you often sweating a lot? 1 2 3 4 5
Is your skin often oily (greasy)? 1 2 3 4 5
Do you suffer from dizziness upon getting out of bed? 1 2 3 4 5
Is it hard for you turning over in bed? 1 2 3 4 5
Could your general condition be called rigid? 1 2 3 4 5
Do you suffer from Lack of movement? (Akinesia) 1 2 3 4 5
How often do you fall? 1 2 3 4 5
Is it sometimes hard for you to start a movement? 1 2 3 4 5
Is it sometimes impossible for you to move at all? 1 2 3 4 5
Do you have problems sustaining a movement? 1 2 3 4 5
Do you often have moments of a decreased libido? 1 2 3 4 5
Do you often have moments of a increased libido? 1 2 3 4 5

The Head
Is it difficult for you to speak loudly? 1 2 3 4 5
Is it difficult for you to speak clearly? (articulation) 1 2 3 4 5
How often do you have a mask-like face? (Frozen facial expression) 1 2 3 4 5
Do you often have involuntary eyelid contractions? 1 2 3 4 5
Does your tongue frequently hurt or do you have gum problems? 1 2 3 4 5
Do you often have red or irritated eyes? 1 2 3 4 5
Do you sometimes hear whistling sounds inside your ear? 1 2 3 4 5
Is it hard for you to see clearly? 1 2 3 4 5
Do you have a poor sense of smell? 1 2 3 4 5
Do you have difficulties swallowing? 1 2 3 4 5
Does your chin tremble often? 1 2 3 4 5
Does your tongue quiver? 1 2 3 4 5
Do you often drool? 1 2 3 4 5
Do you often choke? 1 2 3 4 5
Do you have trouble chewing? 1 2 3 4 5
Do you have any difficulty keeping your head steady? 1 2 3 4 5

The Upper Body
Do the neck muscles on the left side often feel painful? 1 2 3 4 5
Do the neck muscles on the right side often feel painful? 1 2 3 4 5
Do you suffer from pain in the lower back? 1 2 3 4 5
Does your left shoulder often hurt? 1 2 3 4 5
Does your right shoulder often hurt? 1 2 3 4 5
Does your left breast muscle often feel painful? 1 2 3 4 5
Does your right breast muscle often feel painful? 1 2 3 4 5

General Health
Do you suffer from dribbling or dripping at the end of urination? 1 2 3 4 5
Do you often have a weak or interrupted flow of urine? 1 2 3 4 5
Do you often have urinary tract infections? 1 2 3 4 5
Do you have thyroid problems? 1 2 3 4 5
Do you have a heart disease? 1 2 3 4 5
Do you have persistent infections of the airways? 1 2 3 4 5
Do you suffer from allergies? 1 2 3 4 5
Do you have a skin problem? 1 2 3 4 5
Do you have dental problems? 1 2 3 4 5
Do suffer from hair loss? 1 2 3 4 5
Do you have a problem holding your urine? 1 2 3 4 5
Do you have a problem holding your stools? 1 2 3 4 5
Do you often have constipation? 1 2 3 4 5

Upper Limbs
Do you have trouble manipulating objects? (Problems with manual dexterity) 1 2 3 4 5
Does your left arm/hand often tremble? 1 2 3 4 5
Does your right arm/hand often tremble? 1 2 3 4 5
Do you often have cramps in your left arm/hand? 1 2 3 4 5
Do you often have cramps in your right arm/hand? 1 2 3 4 5
Does your left arm/hand feel powerless? 1 2 3 4 5
Does your right arm/hand feel powerless? 1 2 3 4 5
Do you no longer swing your left arm while walking? 1 2 3 4 5
Do you no longer swing your right arm while walking? 1 2 3 4 5
Do you have trouble writing? 1 2 3 4 5
Do you often have a trembling thumb? (money counting motion) 1 2 3 4 5

Lower Limbs
Do you suffer from Toe numbness? 1 2 3 4 5
Do you frequently have the feeling of walking on cushions? 1 2 3 4 5
Do you sometimes drag the left leg? 1 2 3 4 5
Do you sometimes drag the right leg? 1 2 3 4 5
Do you often have fatigue in your left foot/leg? 1 2 3 4 5
Do you often have fatigue in your right foot/leg? 1 2 3 4 5
Do you often have cramps in your left foot? 1 2 3 4 5
Do you often have cramps in your right foot? 1 2 3 4 5
Do you often have cramps in your left leg? 1 2 3 4 5
Do you often have cramps in your right leg? 1 2 3 4 5
Do you often have cramps in the toes of the left foot? 1 2 3 4 5
Do you often have cramps in the toes of the right foot? 1 2 3 4 5
Do you suffer from cold hand/foot on the left site? 1 2 3 4 5
Do you suffer from cold hand/foot on the right site? 1 2 3 4 5
Is it hard for you to relax your arms/legs? 1 2 3 4 5
Do you sometimes have swollen feet? 1 2 3 4 5

Operations
Did you have surgery on the subthalamic Nucleus? no yes
Did you have surgery on the pallidus? no yes
 

Medication
Please check how many milligrams of the following medicine you use :
Symmetrel®(amantadine)
Permax® (pergolide)
Requip® (ropinirol)
Mirapex® (USA) Mirapexin®(UK) Sifrol® (nl)Mirapexim®(vl) (pramipexol)
Sinemet® (levodopa + carbidopa)
Prolopa®(vl) Madopar®(nl) (levodopa + benserazide)

Check out the medication you use:
Parlodel® (bromocriptine)
Comtan®(entacapone)
Akineton® (biperideen)
Azilect® Rasagiline®
Eldepryl® Selegiline®
Apomorphine®
Rotigotine patch®
Duodopa®
Tasmar®
Artane®
 

Remarks