© 2024 Genesis Parkinson’s Institute

Medical Questionnaire and History Form

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Name
Had difficulty doing the leisure activities which you would like to do?
Had difficulty looking after your home, e.g. DIY, housework, cooking?
Had difficulty carrying bags of shopping?
Had problems walking half a mile?
Had problems walking 100 yards?
Had problems getting around the house as easily as you would like?
Had difficulty getting around in public?
Needed someone else to accompany you when you went out?
Felt frightened or worried about falling over in public?
Been confined to the house more than you would like?
Had difficulty washing yourself?
Had difficulty dressing yourself?
Had problems doing up your shoe laces?
Had problems writing clearly?
Had difficulty cutting up your food?
Had difficulty holding a drink without spilling it?
Felt depressed?
Felt isolated and lonely?
Felt weepy or tearful?
Felt angry or bitter?
Felt anxious?
Felt worried about your future?
Felt you had to conceal your Parkinson's from people?
Avoided situations which involve eating or drinking in public?
Felt embarrassed in public due to having Parkinson's disease?
Felt worried by other people's reaction to you?
Had problems with your close personal relationships?
Lacked support in the ways you need from your spouse or partner?
If you do not have a spouse or partner tick here
Lacked support in the ways you need from your family or close friends?
Unexpectedly fallen asleep during the day?
Unexpectedly fallen asleep during the day? (copy)
Unexpectedly fallen asleep during the day? (copy) (copy)
Had problems with your concentration, e.g. when reading or watching TV?
Felt your memory was bad?
Had distressing dreams or hallucinations?
Had difficulty with your speech?
Felt unable to communicate with people properly?
Felt ignored by people?
Had painful muscle cramps or spasms?
Had aches and pains in your joints or body?
Felt unpleasantly hot or cold?
Do you drink alcohol
Do you smoke
Do you have hypertension or hypotension
Do you have a history of seizures
Do you have Diabetes
If yes, are you insulin dependent
Hepatitis A, B, or C
Jaundice
Thyroid Problems
Respiratory Problems
Renal Disease
Nerve Damage
Stroke
HIV / AIDS
Bleeding
Liver Problems
Tuberculosis
Asthma

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© 2024 Genesis Parkinson’s Institute.