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Parkinson’s Questionaire
Complex Care Counselling
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Parkinson’s Questionaire
Parkinsons Disease Questionnaire
Identification
First name
*
First name
*
Post Code
Date of Birth
*
GP Practice Name
*
Funding
*
Self-Paid (Start within 10 Days)
Self-Paid to Start & NHS Application
NHS Application Only (Average 12 Weeks)
Your Situation
Your Stage
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 1
During this initial stage, the person has mild symptoms that generally do not interfere with daily activities. Tremor and other movement symptoms occur on one side of the body only. Changes in posture, walking and facial expressions occur.
Stage 2
Symptoms start getting worse. Tremor, rigidity and other movement symptoms affect both sides of the body or the midline (such as the neck and the trunk). Walking problems and poor posture may be apparent. The person is able to live alone, but daily tasks are more difficult and lengthier.
Stage 5
This is the most advanced and debilitating stage. Stiffness in the legs may make it impossible to stand or walk. The person is bedridden or confined to a wheelchair unless aided. Around-the-clock care is required for all activities.
Stage 4
At this point, symptoms are fully developed and severely disabling. The person is still able to walk and stand without assistance but may need to ambulate with a cane/walker for safety. The person needs significant help with activities of daily living and is unable to live alone.
Stage 3
Considered mid-stage, loss of balance (such as unsteadiness as the person turns or when he/she is pushed from standing) is the hallmark. Falls are more common. Motor symptoms continue to worsen. Functionally the person is somewhat restricted in his/her daily activities now but is still physically capable of leading an independent life. The disability is mild to moderate at this stage.
Care
Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Are you in care?
No
Supportive Care
Palliative Care
Hospice Care
Other
Other
Hours
Part-time
Full-time
Live-in
Other
Other
If you are human, leave this field blank.
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