Parkinson's Database Sample Survey

This Survey contains many questions relating to your general demographics, lifestyle and health. It is completely anonymous and the question responses are randomized. This means that even we are unable to determine which participant answered which questions. Your IP address, URL and web server are not tracked in this survey.  

There will be no follow ups to this survey. You must register and take the official survey for your information to be included in research data.

The reason for registration is so that the important follow up surveys can only be completed by invitation for those that have completed the initial survey. This is the sole purpose of the PDC I.D.

 

This is an unrestricted sample survey. None of the responses will be recorded into the Parkinson's Database.

Media and Physicians may also take this sample survey.

ALL INFORMATION CONTAINED HEREIN IS PROTECTED UNDER U.S. COPYRIGHT LAW AND MAY NOT BE REDISTRIBUTED OR REPRODUCED IN ANY WAY.

There are 115 questions in this survey.
A note on privacy
This survey is anonymous.
The record kept of your survey responses does not contain any identifying information about you unless a specific question in the survey has asked for this. If you have responded to a survey that used an identifying token to allow you to access the survey, you can rest assured that the identifying token is not kept with your responses. It is managed in a separate database, and will only be updated to indicate that you have (or haven't) completed this survey. There is no way of matching identification tokens with survey responses in this survey.
General Questions
This initial set of questions pertains to diagnosis, general activity and basic symptoms.
1 *Is this form being competed with assistance?
2 *

Have you or the person you are completing this form for been diagnosed with

Parkinson's?


HelpIf you have been diagnosed with another neurological syndrome please select 'No'. You will given options on the next question.
4 *Is the diagnosis 'Idiopathic' or without known cause?
5 *What is your total UPDRS for parts I, II & III? (If known)
Each answer must be between 0 and 176

Only numbers may be entered in this field.

HelpIf your Doctor has not given you this information enter 0.
6 *What is your total UPDRS score for parts IV & V? (If known)
Each answer must be between 0 and 23

Only numbers may be entered in this field.

HelpIf your Doctor has not given you this information enter 0
7 *Are you incapacitated?
Choose one of the following answers
8 *Are you able to work?
Choose one of the following answers
9 *Do you require assistance or a care giver?
11 *Is your condition painful?
15 *Are your symptoms consistent from day to day?
16 *Do you get relief from your symptoms by resting? (Even if temporary)
17 *

Are your symptoms present when you run or perform other vigorous physical

activities? (biking, exercising, etc.)


Demographics

These questions relate to your basic demographics and medical questions such as general location, age,

living situation, tests performed, drugs presscribed etc. None of the information requested is personally identifiable.

18 *What is your age?
Each answer must be between 0 and 110

Only numbers may be entered in this field.

19 *At what age were you diagnosed?
Each answer must be between 0 and 110

Only numbers may be entered in this field.

20 *What is your gender?
21 What is your height?
Each answer must be between 0 and 9

Only numbers may be entered in these fields

HelpThis is a voluntary question. In conjunction with the next question it will give us a BMI average for parkinsons which may be important. 
22 What is your weight?
Each answer must be between 0 and 999

Only numbers may be entered in this field.

HelpThis is voluntary and will only be used to calculate BMI which might be important.
23 *

What do you consider your ethnicity? (Please answer as completely as

possible, If we see incidence we will ask more detailed information on ethnicity

in an update.)
Check any that apply
24 What is your eye color?
Choose one of the following answers
HelpThis is not a mandatory question, but it may help to detemine genetic predisposition.
25 What is your hair color?
Choose one of the following answers
HelpThis is not a mandatory question, but it may help to reveal genetic dispositions.
26 *Have any members of your family been diagnosed with Parkinson's?
28 *Do you live in the United States?
32 *What type of dwelling do you live in?
Choose one of the following answers
33 *What is the age of your dwelling?
Each answer must be between 1 and 250

Only numbers may be entered in this field.

34 *Do you have Gas Appliances?
35 *

Do you have a wood burning Stove?


36 *What is your primary heat source?
Choose one of the following answers
37 *Do you cook with Charcoal or Wood?
38 *Has your home been remodeled?
40 *

Has there been construction or drilling in areas that you have lived?

(follow up will be asked on update if there is incidence)
41 *Have you lived on or near a Farm?
Check any that apply
42 *What type of water system do you have? (Check all that apply)
Check any that apply
43 *Do you have a recent water quality report?
HelpYou will need to have a copy of your water quality report in front of you to complete the next question. You can follow this link if you would like to obtain one from the EPA. Consumer Confidence Report If you would like to obtain a report and complete this later skip this question.
45 *Do you live near or have you ever lived near overhead power lines?
46 *Do you have or have you ever had an indoor cat?
49 *Do you have or have you had any other animals?
Check any that apply
50 *Have you ever had Mold in your home?
51 *Have you ever lived near a Golf Course or athletic field?
52 *Do you or have you participated in sports on groomed athelitc fields?
53 *Do you maintain your own lawn or landscaping?
Medical

Please answer as completely as possible, these questions are very important.

Your responses cannot be associated to you personally in any way.

 

54 *Do you smoke cigarettes?
Choose one of the following answers
HelpIf you quit select the quantity and continue.
58 *Do you have allergies?
59 *Have you ever had a head injury?
60 *Have you ever had a spinal injury?
61 *Have you had any surgeries?
62 *Have you ever been under Anesthesia?
63 *Do you drink Alcohol?
Check any that apply
64 *Have you ever used drugs or inhalants for recreational purposes?
Check any that apply
65 *

What other medical conditions do you have or have you had in the past?

(Diagnosed or Suspected)


Check any that apply
66 Have you ever been suspected of having Lyme Disease?
68 *What Medicals tests have you had?
Check any that apply
69 *

Were any of the tests positive or conclusive?


Check any that apply
72 *What motor symptoms are affected?
Check any that apply
73 *Are your symptoms Bi-Lateral or Uni-Lateral?
Check any that apply
74 *

Is only your dominant side affected, or was only your dominant side

affected at initial onset?


75 *What part of the body is affected?
Check any that apply
76 *What non motor symptoms do you exhibit?
Check any that apply
77 *What medications have you been treated with?
Check any that apply
HelpPlease list only prescribed medications. If you have been prescribed other medicines (for Parkinson's) please e-mail them to survey@parkinsonsdatabase.net and we will add them on a follow up survey.
79 *What non drug treatments have you had?
Check any that apply
HelpIf you have used other non-drug treatments (for Parkinson's) please e-mail them to survey@parkinsonsdatabase.net and we will add them on a follow up survey.
80 *Were any of them effective?
Check any that apply
81 *Do you have any of the following Vitamin Deficiencies?
Check any that apply
82 *Have you had any of the following Immunizations?
Check any that apply
83 *What types of Physicians have you seen for this condition?
Check any that apply
Help

This includes Physicians that have reviewed your test results.

84 *Do you have or have you had any dental fillings contaiing Amalgam or Mercury?
86 *How many hours per day on average are you awake?
Choose one of the following answers
HelpThis will provide data that correlates in part to the medications you take.
87 *Do you require naps in the daytime to improve your functionality?
88 *Do you have sleep disturbances?
HelpSelect 'Yes' if your sleep patterns have changed since your illness began. There are follow up questions for this.
Diet

This portion of the Survey regards diet. If you consume any of the foods listed

once per week or more, you should check the applicable box.

93 *Do you eat canned goods?
Check any that apply
94 *Do you eat frozen prepared foods?
Check any that apply
95 *Do you drink any of the following products?
Check any that apply
96 *Do you eat any of the following Dairy products?
Check any that apply
97 *Do you eat any of the following fast foods?
Check any that apply
98 *Do you consume any of the following?
Check any that apply
99 *Do you consume any of the following products that may contain Aspartame?
Check any that apply
100 *Do you eat products that contain Gluten?
Check any that apply
101 *Do you eat Wild Game or Foul?
102 *Do you eat fish caught fresh from any of the following areas?
Check any that apply
103 *Do you eat Shellfish or Crustaceans?
104 *Do you knowingly eat foods grown from genetically modified organisms?
Chemicals

This group of questions relates to which chemicals that you have used

or currently use in your place of living. These are very important questions,

please complete them as thoroughly as possible.

As a rule of thumb if you use these products more than once a year or have

knowingly absorbed or ingested them, then you should check the box.

There will most certainly be updates to this section.

105 *Do you knowingly use products Containing BPA?
106 *Do you use products containing 2,4-D?
107 *Do you use any of the following chemicals?
Check any that apply
HelpClick on the underlined chemicals for information.
108 *Do you use products containing Teflon?
109 *Do you always wash new clothing before you wear it?
Work Exposure

This section pertains to your past and present work environments.

Please select the industries that you have worked in for more than 3 months.

If no industries apply to you, please select other.

110 *Have you worked in any of the following Industries?
Check any that apply
111 *Have you ever had contact with 'Agent Orange'?
112 *Have you ever come in contact with Napalm?
Medications

This section details which common medications you have taken as well as asking

what you currently take.

113 *What medications have you taken in the past?
Check any that apply
HelpSee next question for links and references.
114 *What medications do you currently take?
Check any that apply
115 *What Supplements do you take?
Check any that apply