Please rate the severity of your symptoms over the past 7 days, on average. The more severe and debilitating the symptom, slide right. If you're not having that symptom, slide to the left. Slowness* must provide value
Constipation (incomplete bowel emptying)* 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 or 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
How it has been, on average, over the past week
Balance* must provide value
Control of Body Temperature * must provide value
Dizzy on standing* must provide value
Visual Disturbance* must provide value
Insomnia* must provide value
REM Sleep Behavior Disorder* must provide value
Restless Leg Syndrome* 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
on/ off, nausea, dyskinesia, etc.
Sexual Dysfunction* must provide value
Urinary symtpoms * must provide value
Hallucinations or Delusions * must provide value
Nausea* must provide value
Age
Years since PD diagnosis
Do you have a diagnosis of Parkinson's disease?* must provide value
No. I'm a healthy control.
PD suspected, not diagnosed.
I have something related to PD, but it's not PD.
I have a diagnosis of PD
Gender Female Male
Do we have your permission to use your data for research? * must provide value
Yes
No
Cumulative Score= Sum of all variables View equation
We are trying to eradicate PD and improve the lives of those currently affected. Yes
No
Name
Email address:
How do you score? Please contact lmischley@bastyr.edu for questions about using this scale.
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