Name_________________________________________

Tel. number____ __________________

Age______ Gender________________

Please check all that apply:

1. I have been diagnosed and treated for Parkinson’s disease for:

________1-3 years ________3-5 years ________more than 5 years

2. My daily intake of Levadopa (Sinemet) is:

_______1-3 pills per day ______3-5 pills per day _______more than 5 pills

3. I have experienced these side effects from Sinemet:

_______dyskinesia _______hallucinations _______nausea/vomiting

_______low blood pressure _______delusions

4. My symptoms include:

_______tremor _______freezing of gait _______stiffness _______slowness

Other symptoms not listed:

5. I experience on/off motor fluctuations:

________occasionally _________frequently _________most of the time