Please download and review the participant information sheet if you have not already.
"I have read the participant information sheet and I do not have any questions about participation. I voluntarily consent to participate in this study. I understand that future questions I may have about the research or about my rights as a participant will be answered by study staff at 425-602-3306 or
[email protected] ."
Do you consent to participate?
By consenting online, you no longer need to sign and mail in a paper copy of the consent form.
Yes
No
TO SAVE YOUR INFORMATION & RETURN AT A LATER TIME:
Who is completing this survey?
1. Person with Parkinsonism/ Parkinson's disease (PWP)
2. Friend/ caregiver, in the presence of PWP (for instance, if motor symptoms make keyboard use difficult, or if PWP is not comfortable on computer.)
3. Other
Please describe who is completing this form and your relationship to the PWP:
Create a PATIENT RECORD ID:
* must provide value
example: ABCD84
Today M-D-Y
Your date of birth:
* must provide value
Today M-D-Y
Has your name, address or other personal information changed since you last completed the survey?
* must provide value
Yes
No
United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo - Democratic Republic of the Congo - Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Yemen Zambia Zimbabwe
Country within the United Kingdom
England Northern Ireland Scotland Wales
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Marianas Islands North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland and Labrador (NL) Northwest Territories (NT) Nova Scotia (NS) Nunavut (NU) Ontario (ON) Prince Edward Island (PE) Quebec (QC) Saskatchewan (SK) Yukon (YT)
State , province, or region
Have you received a new diagnosis or has your diagnosis or thoughts of your diagnosis changed?
* must provide value
Yes
No
Parkinson's disease/ Idiopathic Parkinson's disease (PD)
Parkinsonism
Multiple system atrophy (MSA)/ Shy-Drager syndrome
Progressive supranuclear palsy (PSP)
Corticobasal degeneration (CBD)
Dementia with Lewy bodies (DLB)
Pick's disease
Olivopontocerebellar atrophy (OPCA)
Other
I don't have a diagnosis but believe I may be at increased risk of parkinsonism
Date of Parkinson's diagnosis?
Today M-D-Y
What is the approximate month, day, and year that you first began having motor symptoms related to PD, even before your diagnosis?
Today M-D-Y
If other, please describe:
Was your diagnosis made by:
Primary care provider / general medicine practitioner
Neurologist, general
Neurologist, movement disorders specialist
Other
If other, who made your diagnosis?
I believe my diagnosis is correct / accurate.
True
False
True
False
Was there a delay in your diagnosis?
Yes
No
What were you originally diagnosed with?
Did people think your symptoms were "all in your head"?
Yes
No
Over the past 6 months, would you say your disease has:
Improved Been stable Worsened
Which stage best represents your disease?
1-sided symptoms only, minimal disability Both sides affected, balance is stable Mild to moderate disability, balance affected Severe disability, able to walk and stand without help Confinement to bed or wheelchair unless aided Don't know
Yes
No
Have you had a clear and dramatic beneficial response to dopaminergic therapy?
Yes, during initial treatment with dopamine (e.g., levodopa), my function returned to near-normal or normal. (Mild changes do not qualify)
No
I have never done a therapeutic trial of dopaminergic therapies (e.g., levodopa).
By which percent does dopamine repletion improve your symptoms?
I can feel my dopaminergic medicines "kick in" and/or "wear off."
True
False
Not applicable / do not take dopamine (e.g., levodopa)
Slowness
* must provide value
Constipation (incomplete bowel empyting)
* must provide value
Walking
* must provide value
Freezing
* must provide value
Falling
* must provide value
Rising from seated position
* must provide value
Dressing, Eating, Grooming
* must provide value
Motivation & Initiative
* must provide value
Handwriting & Typing
* must provide value
Depression (feeling sad, blues)
* must provide value
Loss of Interest
* must provide value
Anxiety
* must provide value
Fatigue
* must provide value
Daytime Sleepiness
* must provide value
Dyskinesia
* must provide value
Tremor
* must provide value
Sense of balance
* must provide value
Control of Body Temperature
* must provide value
Dizzy on standing
* must provide value
Visual disturbance
* must provide value
Insomnia (inability to sleep)
* must provide value
Sleep behavior disorder (e.g. acting out dreams)
* must provide value
Restless Legs- Urge to move legs in order to stop unpleasant sensations
* must provide value
Muscle cramping, pain, or aching
* must provide value
Speech
* must provide value
Drooling
* must provide value
Stooped posture
* must provide value
Memory/ Forgetfulness
* must provide value
Comprehension
* must provide value
Sense of smell
* must provide value
Medication Side Effects
* must provide value
Sexual dysfunction
* must provide value
Urinary symptoms
* must provide value
Hallucinations or Delusions
* must provide value
Nausea
* must provide value
View equation Please mark box if you have taken any of the following consistently over the past 6 months.
Alpha-Lipoic acid
Coconut oil
Vitamin B12 (methylcobalamin, cyanocobalamin)
Vitamin C
Calcium
Vitamin D
CoQ10
DHEA
Estrogen
Fish Oil
NADH
Gingko biloba
Glutathione, oral
Glutathione, intranasal
Inosine
Iron (Fe)
Lithium, low dose
Marijuana (edible)
Marijuana (inhaled)
Melatonin
Probiotics
Quercetin
Resveratrol
Homocysteine Factors (B6, B12, folic acid, betaine)
Turmeric/ curcumin
5 methyltetrahydrofolate (5-MTHF)
Multivitamin/ Mineral
N-acetyl cysteine (NAC)
Low dose naltrexone
Mucuna
Fava beans
Dance for PD
Tremble Clefs program
Lee Silverman Voice Treatment
High Dose Thiamine (Vitamin B1), Oral
High Dose Thiamine (Vitamin B1), Intramuscular
Lion's Mane mushroom
Other medicinal mushrooms (reishi, cordyceps, chaga, agaricus, etc.)
Testosterone, Intramuscular
Testosterone, Topical
Mannitol
NAD+ (or NR or NMN)
Intravenous micronutrient therapy (e.g., IV vitamins)
Intramuscular micronutrient therapy (e.g., B12 injections)
Intravenous exosome therapy
Red light therapy
Farnesol
What type of oral glutathione do you take?
Capsules or tablets (e.g., Jarrow brand) Liposomal glutathione (e.g., Quicksilver brand)
What type of mucuna do you take?
Please specify what type of mucuna you are taking (brand, dose, etc.).
What type of probiotic do you take?
Are you taking oral NAD+ (pill) or NAD+ via IV?
Oral (pill)
IV
Both
What type/brand of NAD+ are you taking?
Have you followed any of these diets consistently in the last 6 months? (check all that apply)
What type of vegetarianism?
Vegetarian, lacto-ovo (dairy and eggs, no meat) Vegetarian, ovo (eggs, no dairy or meat)
Music
On how many of the last seven days did you participate in at least 30 minutes of physical activity?
0 1 2 3 4 5 6 7
What kind of physical activity? (check all that apply)
What "Other" activity do you do?
For how long did you participate?
At what intensity level did you engage, on average, while doing the activity?
1- barely moving
2
3 - increased heart rate, breaking a sweat
4
5- maximum effort
I regularly take live, in-person fitness classes.
True
False
I regularly take online, virtual fitness classes.
True
False
Do you participate in any of the following online workout programs with a PD-specialized physical therapist or fitness professional?? (please select all that apply)
Please type the name of the online workout program that you participate in:
I regularly see a physical therapist (in person or online).
True
False
Please select which of the following describes your weight over the last 6 months:
My weight has remained stable
I've gained weight - intentionally
I've gained weight - unintentionally
I've lost weight - intentionally
I've lost weight - unintentionally
This questionnaire is about activities that you may have done in the past 4 weeks. how many TIMES a week you usually did it, and write your response in the space provided.in a typical week you did the activity.Here is an example of how Mrs. Jones would answer question #1: twice a week. She usually spends one hour on Monday with Maria and two hours on Wednesday with Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week.
In a typical week during the past 4 weeks, did you... 1. Visit with friends or family (other than those you live with) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
2. Go to the senior center ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
4. Attend church or take part in church activities ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
5. Attend other club or group meetings ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 7. Dance (such as square, folk, line, ballroom)(do not count aerobic dance here) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
8. Do woodworking, needlework, drawing, or other arts or crafts?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
9. Play golf, carrying or pulling your equipment (count walking time only)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
10. Play golf, riding a cart (count walking time only)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
11. Attend a concert, movie, lecture, or sport event ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
12. Play cards, bingo, or board games with other people ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 13. Shoot pool or billiards ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
14. Play singles tennis (do not count doubles) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
15. Play doubles tennis (do not count singles) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
16. Skate (ice, roller, in-line)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
17. Play a musical instrument?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
19. Do heavy work around the house (such as washing windows, cleaning gutters)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 20. Do light work around the house (such as sweeping or vacuuming)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
21. Do heavy gardening (such as spading, raking)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
22. Do light gardening (such as watering plants) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
23. Work on your car, truck, lawn mower or other machinery?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
** Please note: For the following questions about running and walking, include use of a treadmill. Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
25. Walk uphill or hike uphill (count only uphill part)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 26. Walk fast or briskly for exercise (do not count walking leisurely or uphill)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
27. Walk to do errands (such as to/from a store or to take children to school) (count walk time only )?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
28. Walk leisurely for exercise or pleasure?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
29. Ride a bicycle or stationary cycle?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
30. Do other aerobic machines such as rowing, or step machines (do not count treadmill or stationary cycle) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
31. Do water exercises (do not count other swimming) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 32. Swim moderately or fast ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
34. Do stretching or flexibility exercises (do not count yoga or Tai-chi) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
36. Do aerobics or aerobic dancing ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
37. Do moderate to heavy strength training (such as hand-held weights of more than 5 lbs. , weight machines, or push-ups) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you...
38. Do light strength training (such as hand-held weights of 5 lbs. or less or elastic bands) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
39. Do general conditioning exercises, such as light calisthenics or chair exercises (do not count strength training) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
40. Play basketball, soccer, or racquetball (do not count time on sidelines) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
41. Do other types of physical activity not previously mentioned ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
THANK YOU FOR COMPLETING THE CHAMPS PHYSICAL ACTIVITY QUESTIONS, PLEASE CONTINUE WITH THE REST OF THE SURVEY BELOW.
In general, would you say your health is:...
Excellent
Very good
Good
Fair
Poor
In general, would you say your quality of life is:...
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your physical health?...
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your mental health, including your mood and your ability to think?...
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your satisfaction with your social activities and relationships?...
Excellent
Very Good
Good
Fair
Poor
In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)...
Excellent
Very Good
Good
Fair
Poor
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?...
Completely
Mostly
Moderately
A little
Not at all
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?...
Never
Rarely
Sometimes
Often
Always
How would you rate your fatigue on average?...
None
Mild
Moderate
Severe
Very Severe
How would you rate your pain on average?...
1 No pain
2
3
4
5
6
7
8
9
10 Worst imaginable pain
Do you NOW smoke cigarettes every day, some days, or not at all?
Every day Some days Not at all Don't know
How old were you when you FIRST started to smoke fairly regularly?
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
Yes
No
How long has it been since you quit smoking cigarettes? (enter number here and unit of time below)
How long has it been since you quit smoking cigarettes? (Time period)
Days
Weeks
Months
Years
Don't know
On the average, how many cigarettes do you now smoke a day?
On how many of the PAST 30 DAYS did you smoke a cigarette?
On the average, when you smoked during the PAST 30 DAYS, about how many cigarettes did you smoke a day?
During the PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO QUIT SMOKING?
Yes No Don't know
To the best of your ability, please describe the jobs you have held, the work required during your employment, and any potential environmental exposures encountered as part of your work?
I eat most meals at home.
True
False
True
False
I sometimes cook with an air fryer.
True
False
How many times do you use an air fryer per month?
I routinely prepare meals for others.
True
False
It is difficult to afford groceries.
True
False
I find it difficult to afford healthy food.
True
False
I buy food from local farmers (co-op, farmer's markets).
True
False
I try to eat organically grown foods when possible.
True
False
True
False
True
False
True
False
True
False
True
False
I avoid artificial sweeteners.
True
False
True
False
I avoid artificial colors, flavors, etc.
True
False
True
False
True
False
True
False
True
False
True
False
I regularly experience feelings of guilt.
True
False
True
False
Do you experience any feelings of discomfort or discrimination due to your Parkinson's disease as a result of the following? (check all that apply)
If other, please specify:
I regularly attend a live, in-person support group.
True
False
I regularly attend an online, virtual support group.
True
False
I regularly attend online, virtual happy hours.
True
False
I speak with someone on the phone or through video conferencing daily.
True
False
I regularly see a psychotherapist, counselor, or coach (in person on online).
True
False
If you have had counseling, please indicate who performed the sessions.
Approximately how many therapy/counseling sessions have you had?
Approximately how many different therapists/counselors have you worked with?
Please describe the type of therapy / coaching / counseling that you participate in:
True
False
I frequently babysit or spend time with my grandchildren.
True
False
Are you currently the primary caregiver of others (is it your responsibility that their needs are met)?
Yes
No
How many years have you been a caregiver?
For whom do you provide care? (please check all that apply)
Are you currently a single parent?
Yes
No
For how many children are you a single parent?
I practice calorie restriction.
True
False
True
False
True
False
True
False
I use an app for meditation and/or relaxation.
True
False
Please type the name of the app(s) that you use for meditation and/or relaxation:
I regularly listen to live music.
True
False
I regularly listen to recorded music.
True
False
I regularly sing or play an instrument by myself.
True
False
I regularly sing or play an instrument with others.
True
False
True
False
I use marijunana.
True
False
True
False
I can name 6 foods on the dirty dozen.
True
False
I practice stress management.
True
False
Please describe what type of stress management do you practice.
I have amalgam (silver) fillings.
True
False
True
False
True
False
True
False
In which armed service did your serve?
Yes
No
In combat, would you consider your involvement:
Mild
Moderate
Intense
Did you spend time at Camp Lejeune?
Yes
No
How much time did you spend at Camp Lejeune?
Less than 1 month
1-3 months
3 months- 1 year
More than 1 year
Were you exposed to Agent Orange?
Yes
No
I don't know
If you were exposed to Agent Orange, would you consider your exposure to be:
Mild
Moderate
Severe
True
False
What type of pet(s) do you have?
True
False
True
False
I read an educational book.
True
False
I find it difficult to care for myself.
True
False
I have had deep brain stimulation surgery (DBS).
True
False
GPi
STN
I don't Know
I have difficulty falling asleep.
True
False
I have difficulty staying asleep.
True
False
Over the past month, what percentage of the time do you wake feeling rested? (Please click and drag the slider bar.)
Have you ever been told, or suspected yourself, that you seem to 'act out your dreams' while asleep (for example, punching, flailing your arms in the air, making running movements, etc.)?
Yes
No
I drink mostly unfiltered tap water.
True
False
I drink mostly filtered tap water.
True
False
I drink mostly glass bottled water.
True
False
I drink mostly plastic bottled water.
True
False
Estimate the number of plastic bottles of water you drink per week.
I drink mostly canned water (e.g., flavored fizzy water).
True
False
Estimate the number of cans of water (or fizzy water) you drink per week.
I drink mostly mineral water.
True
False
Over the past week, on average, how many ounces of water (excluding tea, soda, juice) did you drink daily? One cup or glass of water is about 8 oz. Please refer to this image to help you with this calculation.
Less than 16 oz total per day (less than 2 cups)
Between 16 - 32 oz total per day (2 - 4 cups)
Between 32 - 48 oz total per day (4 - 6 cups)
Between 48 - 64 oz total per day (6 - 8 cups)
Between 64 - 80 oz total per day (8 - 10 cups)
Between 80 - 96 oz total per day (10 - 12 cups)
Between 96 - 112 oz total per day (12 - 14 cups)
Between 112 - 128 oz total per day (14 - 16 cups)
Over 128 oz total per day (more than 16 cups)
Male
Female
Non-binary
What is your current marital or partnership status?
Married
Divorced
Single
Domestic partnership
Other
Caucasian
Black
Hispanic
Native American
Asian / Pacific Islander
Other
What is your natural hair color?
Black
Blond
Brown
Red
Other
Complementary & alternative therapies (CAM)
Conventional therapies
Activity costs
Highest grade level completed:
Less than 8th grade
Grades 9-11
Completed High School/GED
Technical school certification
Associate Degree
Bachelors Degree
Graduate / Professional degree
What is your family's income in past 12 months? (Select all that apply.)
Less than $20,000
Between $20-40,000
Between $40-60,000
Between $60-80,000
Between $80-100,000
Between $100-150,000
More than $150,000
What is your estimated credit score?
Under 300
300-579
580-669
670-739
740-799
800-850
Over 850
Over the past month, would you say your family's spending on living expenses was less than its total income?
Yes
No
Over the last 2 months, have you paid a late fee on a loan or bill?
Yes
No
In the last 3 months, has the utility company shut off your utilities for not paying bills?
Yes
No
In the last 3 months were there any days that your home was not heated or cooled because you couldn't pay the bills?
Yes
No
Do you have a savings account?
Yes
No
Do you have a checking account?
Yes
No
Within the last 3 months I repaid any money I owed on time?
Yes
No
Do you owe anyone money? (Please include banks, friends, family, payday lenders, etc.)
Yes
No
Do you currently have at least 1 financial goal?
Yes
No
Do you currently have a personal budget spending plan or financial plan?
Yes
No
Do you currently have an automatic deposit or electronic transfer set up to put money away for future use?
Yes
No
Yes
No
How many hours per week do you work?
What were the circumstances in which you left your job?
How many miles is your home from the
How many miles is your home from the
Have you ever lived somewhere where you were on a well? (drank well water)
Yes
No
Was the water from the well filtered before drinking and cooking with it?
Yes
No
Was the well water used for showering and bathing filtered before use?
Yes
No
For how many years did you live on well water?
Are you currently drinking water from a well?
Yes
No
What type of filter are you using for your home water?
Do you use olive oil as a main culinary fat?
Yes
No
Do you consume more than 4 tablespoons of olive oil in a given day (including oil used for frying, salads, out-of-house meals, etc.)?
Yes
No
Do you consume more than 2 vegetable servings per day, with at least one of the portions raw or as a salad? (1 serving= 200 g; side dishes should be considered 1/2 a serving)
Yes
No
Do you consume 3 or more fruit units (including nautral fruit juices) per day?
Yes
No
Do you consume less than 1 serving per day of red meat, hamburger, or meat products (ham, sausage, etc.)? (1 serving: 100-150 g)
Yes
No
Do you consume less than 1 serving per day of butter, margarine, or cream? (1 serving=12 g)
Yes
No
Do you consume less than 1 sweet or carbonated beverage drink per day?
Yes
No
Do you drink 7 or more glasses of wine per week?
Yes
No
Do you consume 3 or more servings of legumes per week? (1 serving =150 g)
Yes
No
Do you consume 3 or more serrvings of fish or shellfish per week? (1 serving 100-150 g of fish or 4-5 units or 200 g of shellfish)
Yes
No
Do you consume les sthan 3 servings per week of commercial sweets or pastries (not homemade), such as cakes, cookies, biscuits, or custard?
Yes
No
Do you consume 3 or more servings of nuts (including peanuts) per week? (1 serving = 30 g)
Yes
No
Do you preferentially consume chicken, turkey, or rabbit meat instead of veal, pork, hamburger, or sausage?
Yes
No
Do you consume vegetables, pasta, rice, or other dishes seasoned with sofrito (sauce made with tomato and onion, leek, or garlic and simmered with olive oil) at least 2 times per week?
Yes
No
How often do you consume green leafy vegetables? (kale, collards, greens, spinach, lettuce)
2 or fewer servings per week
3-5 servings per week
6 or more servings per week
How often do you consume other vegetabels? (green/red peppers, squash, cooked carrots, raw carrots, broccoli, celery, potatoes, peas or lima beans, potatoes, tomatoes, tomato sauce, string beans, beets, corn, zucchini/summer squash/eggplant, coleslaw, potato salad)
4 or fewer servings per week
4-6 servings per week
1 or more servings per day
How often do you consume berries? (strawberries)
Less than 1 serving per week
1 serving per week
2 or more servings per week
How often do you consume nuts?
Less than once a month
1x/month to 4x/week
5 or more times per week
How often do you consume olive oil?
Not a primary oil
It is the primary oil that I use
How often do you consume butter or margarine?
More than 2 tablespoons per day
1-2 tablespoons per day
Less than 1 tablespoon per day
How often do you consume cheese?
7 or more servings per week
1-6 servings per week
Less than 1 serving per week
How often do you consume whole grains?
Less than 1 serving per day
1-2 servings per day
3 or more servings per week
How often do you consume non-fried fish? (tuna sandwich, fresh fish as main dish; not fried fish cakes, sticks, or sandwiches)
Rarely
1-3 meals per month
1 or more meals per week
How often do you consume beans? (beans, lentils, soybeans)
Less than 1 meal per week
1-3 meals per week
4 or more meals per week
How often do you consume non-fried poultry? (chicken or turkey sandwich, chicken or turkey as main dish and never eat fried at home or away from home)
Less than 1 meal per week
1 meal per week
2 or more meals per week
How often do you consume red meat and related products? (cheeseburger, hamburger, beef tacos/burritos, hot dogs/sausages, roast beef or ham sandwich, salami, bologna, or other deli meat sandwich, beef (steak, roast) or lamb as main dish, pork or ham as main dish, meatballs or meatloaf)
7 or more meals per week
4-6 meals per week
3 or fewer meals per week
How often do you consume fast fried food? (How often do you eat fried food away from home (like French fries, chicken nuggets)
4 or more times per week
1-3 times per week
Less than 1 time per week
How often do you consume pastries and sweets? (biscuit/roll, poptarts, cake, snack cakes/twinkies, Danish/sweetrolls/pastry, donuts, cookies, brownies, pie, candy bars, other candy, ice cream, pudding, milkshakes/frappes)
7 or more times per week
5-6 times per week
4 or fewer times per week
How often do you consume wine?
Never
1 glass per month - 6 glasses per week
1 glass per day
More than 1 glass per day
Chicken
Never
< 1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Turkey
Never
< 1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Beef - 4 ounces or 1 medium patty
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Pork - 4 ounces or 1 medium patty
Never
< 1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Fresh Vegetables - 1/2 cup
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Canned Vegetables - 1/2 cup
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Frozen Vegetables - 1/2 cup
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Fresh Fruit - 1 medium, 1/2 cup
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
What percentage of the time do you buy organic fruits and vegetables?
Cheese - 1 slice, 1/2 oz., 1 Tbsp
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Milk - 1 cup (from cows, do not include non-dairy milks)
Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
5-6x week
Once daily
2-4x day
4-6x day
Never
<1 per month
1 per month
