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A SURVEY FOR PEOPLE WHO TAKE MEDICATION FOR PARKINSON’S DISEASE

If you are currently taking medication for the treatment of Parkinson’s disease (PD), please help us understand how PD affects your life by answering the following questions. This information will be used to explain to doctors how PD affects people’s lives.

1.	What is your home zip code?
2.	What is your current age?	years old
3.	What is your gender?	Male  Female
4.	What is your home status?	I live at home, alone  I live at home, with family/friends who can help me  I live at home, and have a Home Healthcare Aide  I live in an assisted living or nursing facility
5.	How long have you been taking medication for your Parkinson’s disease?	years
6.	In the past month, what was your usual level of independent activity? How well were you able to get around?	Always walk independently, alone  Always walk independently, but with someone nearby  Usually walk independently, but with someone nearby  Sometimes walk independently, but with someone nearby  Sometimes use a walker  Often use a walker
The next few questions are about "off" episodes associated with PD. "Off" episodes are the periods of time in which movement is very difficult. You may have trouble walking, eating, bathing, and even speaking, or you may not be able to move at all. There are two types of "off" episodes: When your Parkinson’s medications feel like they’re "wearing off" When your Parkinson’s symptoms suddenly get worse with little warning to plan
7a.	In the past month, how many times per day have you had an "off" episode?	times per day
7b.	If your "off" episodes do not occur daily, how often do they occur on a weekly basis?	times per week (If you do not have "off" episodes weekly, please stop here)
8a.	How many "off" episodes occurred one hour before taking a dose of Parkinson’s medication(s)?	times (past week)
8b.	How long did these "off" episodes usually last?	minutes (past week)
9a.	How many "off" episodes occurred one hour after taking a dose of Parkinson’s medication(s)?	times (past week)
9b.	How long did these "off" episodes usually last?	minutes (past week)
10.	In the past month, how often could you predict when your medication would "wear off?" (Please choose only one.)	Never Sometimes Occasionally Often Always 0 1 2 3 4
11a.	In the past month, how often did your symptoms return suddenly, with too little warning to plan? (Please choose only one.)	Never Sometimes Occasionally Often Always 0 1 2 3 4
11b.	In the past month, how long did these "off" episodes usually last?	minutes
12.	In the past month, how much have "off" episodes bothered you in regard to your daily activities and mood? (Please choose only one.)	No bother Some bother Moderate bother Major bother 0 1    2    3 4    5    6    7  8    9   10
13.	In the past month, how have "off" episodes limited your activities? (Please check the appropriate box for each activity.)
	No limits Minor limits Moderate limits Major limits Total limits A. Driving a car B. Working at a job C. Working at home D. Physical activities, exercise E. Social activities, going out F. Walking independently G. Getting yourself out of bed or a chair H. Washing up, bathing, showering I. Toileting J. Dressing K. Eating
14.	In the past month, did you feel depressed about having "off" episodes? (Please choose only one.)	Never Occasionally depressed Often depressed Always depressed 0 1    2    3 4    5    6    7  8    9   10
15.	In the past month, did you feel anxious, worried, or nervous about having "off" episodes? (Please choose only one.)	Never Occasionally anxious Often anxious Always anxious 0 1    2    3 4    5    6    7  8    9   10
16.	Compared to a year ago, do you need more help from other people now? (Please choose only one.)	No change Need a little more help Need somewhat more help Need a lot more help 0 1    2    3 4    5    6    7  8    9   10
	Providing your e-mail address will allow us to contact you to participate in future surveys regarding healthcare issues. It is not required and you will not be added to any mailing lists. Thanks for your help.

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