"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 neuroresearch@bastyr.edu."
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:
Scroll to the end of the survey and click on the "Save Record" button. Unsaved data will be lost! 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:
In the box to the RIGHT, please fill in as follows (example: ABCD84):
1st letter of your first name: A
1st letter of your surname or last name: B
1st letter of your mother's maiden name: C
1st letter of your city of birth: D
Last two digits of your birth year: 84* must provide value

example: ABCD84

First Name* must provide value

Last Name* must provide value

Country* must provide value

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* must provide value

England Northern Ireland Scotland Wales
Street address* must provide value

City* must provide value

State or territory* must provide value

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
State* must provide value

Province* must provide value

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
Postal (ZIP) code* must provide value

Email* must provide value

Phone
Today's Date
Today M-D-Y 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?
(If you don't know the date, choose the 15th of the month.)
Today M-D-Y What is your diagnosis?* must provide value

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

If other, please describe:
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
Slowness* must provide value

Tremor* must provide value

Sense of balance* must provide value

Fatigue* must provide value

Daytime Sleepiness* must provide value

Motivation & Initiative* must provide value

Constipation (incomplete bowel empyting)* must provide value

Walking* must provide value

Rising from seated position* must provide value

Dressing, Eating, Grooming* must provide value

Freezing* must provide value

Falling* must provide value

Handwriting & Typing* must provide value

Drooling* must provide value

Speech* must provide value

Visual disturbance* must provide value

Muscle cramping, pain, or aching* must provide value

Restless Legs- Urge to move legs in order to stop unpleasant sensations* must provide value

Sleep behavior disorder (e.g. acting out dreams)* must provide value

Insomnia (inability to sleep)* must provide value

Sense of smell* must provide value

Nausea* must provide value

Depression (feeling sad, blues)* must provide value

Anxiety* must provide value

Loss of Interest * must provide value

Dizzy on standing* must provide value

Stooped posture* must provide value

Memory/ Forgetfulness* must provide value

Comprehension* must provide value

Sexual dysfunction
(loss of libido, erectile dysfunction, difficulty with orgasm)* must provide value

Urinary symptoms
(dribbling, urgency, incontinence)* must provide value

Dyskinesia
(Rocking, writhing, twisting, squirming movements associated with medication)* must provide value

Hallucinations or Delusions
(seeing things that aren't there)* must provide value

PRO-PD Score 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

Rubidium

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

Asea

Dance for PD

Tremble Clefs program

Lee Silverman Voice Treatment

Music Mends Minds

Have you followed any of these diets consistently in the last 6 months? (check all that apply) Anti-inflammatory diet

Calorie restriction

Ketogenic

Paleo diet

Low-carbohydrate

Low-fat

Low-protein

Vegan (no dairy, eggs, or meat)

Vegetarian

Wahls diet

Allergy Avoidance (avoid foods you've been shown to make antibodies to)

No dietary restrictions

Other

What type of vegetarianism? Vegetarian, lacto-ovo (dairy and eggs, no meat) Vegetarian, ovo (eggs, no dairy or meat)
What diet do you follow?
Music
Please mark box if you have consistently engaged in the activity over the past 6 months Listen to music

Play an instrument

Singing

Dancing

Writing music

Reading 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) Swimming

Running

Biking

Hiking

Yoga

Dance

Walking

Climbing

Tai chi

Brian Grant Foundation Powering Forward Boot Camp

Silver Sneakers FLEX Parkinson's Cycling Program

Rock Steady Boxing

Other

The Daily Dose â„¢

The Parkinson's Fitness Project â„¢

What "Other" activity do you do?
For how long did you participate?
(number of minutes per week, total)
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

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

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

Have you smoked at least 100 cigarettes in your ENTIRE LIFE? Yes

No

How old were you when you FIRST started to smoke fairly regularly?
Do you NOW smoke cigarettes every day, some days, or not at all? Every day Some days Not at all Don't know
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?
(If you have answered this question before, only answer this question if your employment history has changed.)
I eat most meals at home. True

False

I cook most of my meals. True

False

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 possilbe. True

False

I am a vegetarian. True

False

I avoid beef. True

False

I avoid pork. True

False

I avoid dairy. True

False

I avoid soda. True

False

I avoid artificial sweeteners. True

False

I avoid sugar. True

False

I avoid artificial colors, flavors, etc. True

False

I go to church. True

False

I pray. True

False

I have lots of friends. True

False

I am lonely. True

False

I practice calorie restriction. True

False

I am overweight. True

False

I use spices liberally. True

False

I meditate. True

False

I smoke tobacco. True

False

I use marijunana.
(You may skip this question if you don't feel comfortable answering.) True

False

I have a lot of stress. True

False

I can name 6 foods on the dirty dozen. True

False

I practice stress management. True

False

I have amalgam (silver) fillings. True

False

I have gold crowns. True

False

I have had root canals. True

False

I am a veteran True

False

I have pets. True

False

I am in a support group. True

False

I read a fictional book. 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

Your date of birth:* must provide value

Today M-D-Y Gender Male

Female

Zip Code
Weight (lbs)
Height (inches)
What is your current marital or partnership status? Married

Divorced

Single

Domestic partnership

Other

Race / Ethnicity: Caucasian

Black

Hispanic

Native American

Asian / Pacific Islander

Other

What is your natural hair color? Black

Blond

Brown

Red

Other

Complementary & alternative therapies (CAM)
(supplements, vitamins, etc.)
Conventional therapies
(co-pays, uncovered prescriptions, etc.)
Activity costs
(gym, classes, memberships, etc.)
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

How many miles is your home from the
nearest highway?
How many miles is your home from the
nearest agricultural area?
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?
Chicken
Serving size: 1 large or two small pieces (4 oz) 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
Serving size: 1 large or two small pieces (4 oz) 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

Canned Fruit - 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 Fruit - 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

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

Cream - 1/4 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

Ice Cream - 1 scoop, ~ 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

Yogurt- 3/4 cup (6 oz) (typical individual container) Never

< 1 per month

1 per month

2-3 per month

1 per week

2-4x per week

5-6x per week

Once daily

2-4x per day

4-6x per day

Butter - 1 tsp 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 dairy products?
Beans - 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

Nuts and Seeds - 1/4 cup or 2 Tbsp spread (e.g. peanut butter) 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

Fish (non-fried) - 4 ounces 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 farm-raised fish?
Fried foods (fries, chicken, etc) - 4 ounces 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

Non-diet soda - 12 ounces, 1 can 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

Diet soda - 12 ounces, 1 can 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

Spices (cinnamon, cloves, etc) - 1/4 teaspoon 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

Oatmeal - 1 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

Eggs - 1 egg 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 eggs?
Bread - 1 slice 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

Pasta - 1 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

What percentage of your pasta and grains gluten-free?
Fresh Herbs (Thyme, Basil, etc) - 1 tsp 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

Wine - 1 med glass, 6 oz 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 drink white wine (or rosÃ©)?
What percentage of the time do you drink red wine?
What percentage of the time do you drink champagne?
Beer - 12 ounce can or bottle 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 drink lagers?
(e.g. Pilsner (Coors, Miller, Bud), Bock, Dunkel, Oktoberfest)
What percentage of the time do you drink ales?
(e.g. Barley wine, Bitter, Brown, India Pale, Pale, Porter, Stout, Wheat)
What percentage of the time do you drink cask ales? (Unfiltered, unpasturized ales)
Liquor - 1 oz 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

Coffee - 8 oz coffee, 1 shot espresso 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

Green tea -1 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

Black tea - 1 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

Olive oil - 1 tsp 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

Coconut oil - 1 tsp 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

Plant-based oils - 1 tsp.
(Safflower, sunflower, canola oil, etc.) 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

Soy - 3 ounces
(tofu, tempeh, etc.) 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

Juice - 8 oz., 1 glass 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

Eat food from a can 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

Drink from plastic bottle 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

Which of the following medications, if any, are you taking? Amantadine (Symmetrel)

Apomorphine (Apokyn)

Benztropine (Cogentin)

Bromocriptine (Parlodel)

Carbidopa, levodopa, and entacapone (Stalevo)

Carbidopa-levodopa (Sinemet)-- Immediate release

Carbidopa-levodopa -- Controlled release

Carbidopa-levodopa -- Extended release

Duodopa

Entacapone (Comtan)

Levodopa-benserazide (Madopar)

Melevodopa (Sirio)

Pramipexole (Mirapex, Mirapex ER, Mirapexin, Sifrol)

Rasagiline (Azilect)

Ropinirole (Adartel, Requip, Requip XL, Ropark)

Rotigotine (Neupro)

Rytary (carbidopa and levodopa)

Selegiline (I-deprenyl, Eldepryl, Zelapar)

Tolcapone (Tasmar)

Trihexyphenidyl (Apo-Trihex, Artane)

Other PD medication

Amantadine (Symmetrel) - Dose
Amantadine (Symmetrel) - Frequency
Apomorphine (Apokyn) - Dose
Apomorphine (Apokyn) - Frequency
Benztropine (Cogentin) - Dose
Benztropine (Cogentin) - Frequency
Bromocriptine (Parlodel) - Dose
Bromocriptine (Parlodel) - Frequency
Carbidopa, levodopa, and entacapone (Stalevo) - Dose
Carbidopa, levodopa, and entacapone (Stalevo) - Frequency
Carbidopa-levodopa (Sinemet)-- Immediate release - Dose
Carbidopa-levodopa (Sinemet)-- Immediate release - Frequency
Carbidopa-levodopa -- Controlled release - Dose
Carbidopa-levodopa -- Controlled release - Frequency
Carbidopa-levodopa -- Extended release - Dose
Carbidopa-levodopa -- Extended release - Frequency
Duodopa - Dose
Duodopa - Frequency
Entacapone (Comtan) - Dose
Entacapone (Comtan) - Frequency
Levodopa-benserazide (Madopar) - Dose
Levodopa-benserazide (Madopar) - Frequency
Melevodopa (Sirio) - Dose
Melevodopa (Sirio) - Frequency
Pramipexole (Mirapex, Mirapex ER, Mirapexin, Sifrol) - Dose
Pramipexole (Mirapex, Mirapex ER, Mirapexin, Sifrol) - Frequency
Rasagiline (Azilect) - Dose
Rasagiline (Azilect) - Frequency
Ropinirole (Adartel, Requip, Requip XL, Ropark) - Dose
Ropinirole (Adartel, Requip, Requip XL, Ropark) - Frequency
Rotigotine (Neupro) - Dose
Rotigotine (Neupro) - Frequency
Rytary (carbidopa and levodopa) - Dose
Rytary (carbidopa and levodopa) - Frequency
Selegiline (I-deprenyl, Eldepryl, Zelapar) - Dose
Selegiline (I-deprenyl, Eldepryl, Zelapar) - Frequency
Tolcapone (Tasmar) - Dose
Tolcapone (Tasmar) - Frequency
Trihexyphenidyl (Apo-Trihex, Artane) - Dose
Trihexyphenidyl (Apo-Trihex, Artane) - Frequency
Other PD Medications - List medications, doses, and frequencies
Supplements, herbs, etc.
(dose, frequency, brand, duration)
examples:
Pharmax finest pure fish oil, 1 Tbsp daily x 4 months
Jarrow Citicoline, 500 mg/ d x 1 year
Centrum multi-vitamin, 2 tabs daily, 10 years
Non-PD Pharmaceutical Prescriptions (not listed above.)
(dose, frequency, duration)
What is your primary source of information for Complementary and Alternative Medical Care?
Books Web / Online Health food / Supplement store Licensed Healthcare Provider Unlicensed Healthcare Provider Other
In the past 6 months, have you consulted any of the following provider types about CAM strategies for PD? ND (naturopathic physician)

MD (medical doctor, conventional physician)

DO (osteopathic physician)

DC (chiropractor)

ARNP (nurse practioner)

LAc (acupuncturist, Traditional Chinese Medicine)

Other

Other CAM
Co- morbidities
List any other diagnosis or illnesses with which you have dealt with over the past 6 months.
(examples: obesity, high blood pressure, hypothyroid, prostate cancer, arthritis, addiction, etc.)
Do you recieve care or attend classes at any of
the following in the past 6 months?
Bastyr Center for Natural Health

Bastyr Clinical Research Center

National College of Naturopathic Medicine

Seattle Integrative Medicine

Powering Forward Boot Camp (BGF/YMCA)

Please list the name of the health care provider(s) you turn to for Parkinson's-related medical advice. This may be your primary care provider, neurologist, movement disorder specialist, etc.
*We will NOT contact this provider on your behalf or share any of your data!
Why are we asking?
If some providers are getting consistently better outcomes than others, we want to know who they are so we can learn from them.
Provider name, provider type, city, and state:
e.g. Jane Smith, ND, Seattle, WA
e.g. Bob Smith, MD, Austin, TX
How did you hear about this study?
Would you like to be contacted if there are any other studies for which you may be eligible? Yes

No

Please tell us anything else you think we should know.
Thank you. You are almost done with this semi-annual survey. At some point over the next 7 days, you will receive an email from us with a link to the ASA24. The ASA24 will ask you to describe all the foods you have eaten in the previous 24 hours. please do your best to eat as you normally do, and complete the survey as soon as you are able once you receive the email. Once you've completed that, you won't hear from us for another 6 months!
Again, your time and efforts are greatly appreciated.
Sincerely,
CAM Care in PD Staff
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