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