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 of your survey responses does not contain any identifying information about you, unless a specific survey question explicitly asked for it. If you used an identifying token to access this survey, please rest assured that this token will not be stored together with your responses. It is managed in a separate database and will only be updated to indicate whether you did (or did not) complete this survey. There is no way of matching identification tokens with survey responses.
General Questions
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?


 If 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)

 If your Doctor has not given you this information enter 0.
6 What is your total UPDRS score for parts IV & V? (If known)

 If your Doctor has not given you this information enter 0
7 Are you incapacitated?
8 Are you able to work?
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
18 What is your age?

19 At what age were you diagnosed?

20 What is your gender?
21 What is your height?
 This 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?

 This 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.)
Aboriginal
African American
African Mainland
Alaskan Native
American Indian
Caucasian
Celtic
Chinese
Czech
English
Filipino
Finnish
French
French
German
Greek
Hawaiian
Hispanic or Latino
Indian (Eastern)
Indonesian
Italian
Jamaican
Japanese
Korean
Latvian
Lebanese
Middle Eastern or Mesopotamian
Mongolian
Pacific Islander
Polish
Portuguese
Puerto Rican
Romanian
Russian
Scandinavian
Scottish
Scottish
South American
Spanish (Europe)
Swedish
Thai
Turkish
Ukraian
Ukrainian
Vietnamese
24 What is your eye color?
 This is not a mandatory question, but it may help to detemine genetic predisposition.
25 What is your hair color?
 This 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?
33 What is the age of your dwelling?

34 Do you have Gas Appliances?
35

Do you have a wood burning Stove?


36 What is your primary heat source?
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?
Crop Producing
Dairy
Livestock
None of the above
42 What type of water system do you have? (Check all that apply)
Community
Municipal
Natural Water Source
Septic
Sewer
Well
43 Do you have a recent water quality report?
 You 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?
Beef Cattle
Birds
Chickens
Dairy Cattle
Dog
Ducks
Fish
Geese
Goats
Horses
Insects
Pig
Reptiles
Rodents
None
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
54 Do you smoke cigarettes?
 If 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?
Never
0-5 drinks per week
5-10 drinks per week
10-20 drinks per week
More than 20 drinks per week
64 Have you ever used drugs or inhalants for recreational purposes?
Amphetamines
Cialis
Cocaine
Cough Syrup
Diet Pills
Formaldehyde (sherm)
Gasoline
Glue
Levitra
Heroin
LSD
Marijuana
Morphine
MDMA (Ecstasy)
None
Opium
Other Inhalants
Oxycontin
Paint
PCP
Percoset
Ritalin
Valium
Viagra
Vicodin
65

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

(Diagnosed or Suspected)


ALS
Alzheimer’s
Arthritis
Asthma
Bi-Polar Disorder
Bladder Infection
Blood Clots
Cancer
Cervical Myelopathy
Circulatory Problems
Constipation
COPD
Epilepsy
Dementia
Dental Problems
Depression
Dermatitis
Diabetes
Dystonia
Eating Disorder
Emphysema
Foot Pain
Gastro-Intestinal issues
Glaucoma
Hair Loss
Heart Attack
Hepatitis
Hernia
High Blood Pressure
HIV
HPV
HSV1
HSV2
IBS
Imbalance
Kidney Disease
Lactose Intolerance
Liver Disease
Low Blood Pressure
Meningitis
MSA
Multiple Sclerosis
Muscle Weakness
Obesity
OCD
Other
Parkinson’s Plus
Pancreatitis
Poor Sense of Smell
Poor Sense of Taste
Psoriasis
Psychiatric Treatment
Rashes
Skin Problems
Stomach Ulcer
Stroke
Thyroid disorder
Traumatic Injury
Tuberculosis
Venereal Disease or other STD
Vertigo
Warts
66 Have you ever been suspected of having Lyme Disease?
68 What Medicals tests have you had?
Anemia
Bone scan
Colonoscopy
EEG
EKG
EMG
Genetic Study
Lumbar puncture
MRI
RPR
Sleep Study
Standard Blood Tests
TCD
Urinalysis
VNG
X-Ray
Other
69

Were any of the tests positive or conclusive?


Anemia
Bone scan
Colonoscopy
CT scan
DAT scan
EEG
EMG
EKG
Endoscopy
Genetic Study
Lumbar puncture
MRI
PET scan
RBR
Sleep Study
Standard Blood Tests
TCD
Urinalysis
VDRL
VNG
EMG
X-Ray
Other
72 What motor symptoms are affected?
Chewing
Cramping
Decreased Arm swing
Drooling
Dystonia
Freezing
Grasping
Lack of Dexterity
Mask like Expression
Micrographia (Small handwriting)
Postural Instability
Reaching
Resting Tremor
Rigidity
Running
Sitting
Slow Movement
Speaking
Standing
Stooped Posture
Tremor
Typing
Unwanted Accelerations
Vision
Walking
Writing
None
73 Are your symptoms Bi-Lateral or Uni-Lateral?
Bi-Lateral (affects both sides)
Uni-Lateral (affects one side)
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?
Back
Feet
Hands
Internal Systems
Left Arm
Left Leg
Neck
Right Arm
Right Leg
76 What non motor symptoms do you exhibit?
Breathing Problems
Constipation
Depression
Excessive Saliva
Fatigue
Fear/ Anxiety
Impulsiveness
Numbness
Poor sense of smell
Poor sense of Taste
Sleep Disturbances
Swallowing Difficulty
Urinary Problems
Weight loss
77 What medications have you been treated with?
Anti Inflamatory
Apokyn
Azilect (Rasagiline)
Benzotropine
Carbidopa-Levodopa
Entacapone
Mirapex
Muscle Relaxers
Percocet
Prednisone
Requip (Ropinorole)
Selegiline
Tolcapone
Triexyphenidyl
Other
 Please 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?
Acupuncture
Ayurvedic Medicine (Holistic)
Bone Marrow Transplant
Botlinum Toxin A
Broad Beans
CoQ10
DBS
Physical Therapy
Exercise
Massage
St. John’s Wort
Stem Cell Therapy
Transfusion
Yoga
Other
 If 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?
Acupuncture
Anti Inflamatory
Apokyn
Ayurvedic Medicine (Holistic)
Azilect (Rasagiline)
Benzotropine
Bone Marrow Transplant
Botlinum Toxin A
Broad Beans
Carbidopa-Levodopa
CoQ10
DBS
Physical Therapy
Entacapone
Exercise
Massage
Mirapex
Muscle Relaxers
Percocet
Prednisone
Requip (Ropinorole)
Selegiline
St. John’s Wort
Stem Cell Therapy
Tolcapone
Transfusion
Triexyphenidyl
Yoga
None
81 Do you have any of the following Vitamin Deficiencies?
A
B
B12
B6
Biotin
C
Calcium
D
E
Folate
Iron
K
Niacin
Riboflavin
Unknown
82 Have you had any of the following Immunizations?
Diphtheria
Hepatitis A
Hepatitis B
HPV
Influenza
Malaria
Measles
Meningococcal
Mumps
Pertussis
Polio
Rabies
Rubella
Tetanus
Varicella
Zoster
83 What types of Physicians have you seen for this condition?
Cardiologist
Chiropractor
Dermatologist
Endocrinologist
Gastrologist
General Practitioner/Family Doctor
Geneticist
Hematologist
Hepatologist
Mental Health Counselor
Naturopath
Nephrologist
Neurologist
Neurophysiologist
Neurosurgeon
Oncologist
Orthopedist
Otolaryngologist
Pain Specialist/Anesthesiologist
Physiatrist
Podiatrist
Proctologist
Psychiatrist
Psychologist
Pulmonologist
Rheumatologist
Sleep Doctor
Urologist
Other
 

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?
 This 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?
 Select 'Yes' if your sleep patterns have changed since your illness began. There are follow up questions for this.
Diet
93 Do you eat canned goods?
Broth
Condiments
Fish
Fruit
Gravy
Jams and Jellies
Meat
Milk
Mushrooms
Pasta
Peanut Butter
Pickled Items
Pudding
Salad Dressing
Sauces
Soups
Tomato Products
Vegetables
94 Do you eat frozen prepared foods?
Breads
Burritos
Fish
Fruit
Ice Cream
Juice
Meat
Pasta
Pies
Pizza
Popsicles
Potatoes
Seafood
Snacks
TV Dinners
Vegetables
95 Do you drink any of the following products?
Alcoholic Mixers
Ale
Bottled water
Breakfast drinks
Coffee
Cordials
Diet soda
Energy Drinks
Flavored Creamer
Hard Liquor
Juices
Lager Beer
Malt
Milk
Non Dairy Creamer
Other flavored beverages
Powdered creamer
Powdered drink mixes
Soda
Tap water
Tea
Weight loss drinks
Wheat Beer
Wine
96 Do you eat any of the following Dairy products?
Aged Cheese
Butter
Cereals
Cheese
Chocolate Milk
Cottage Cheese
Eggs
Evaporated Milk
Flavored Milk
Orange Juice
Processed Cheese
Pudding
Sour Cream
Soy Products
Tofu
Whipped Cream
Yogurt
97 Do you eat any of the following fast foods?
Chicken
Chicken byproducts
Desserts
Eggs
French Fries
Hamburger
Hot Dogs
Onion Rings
Other Meat
Pastries
Pizza
Salads