VIARTIS

 

PARKINSON'S DISEASE

 

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SYMPTOM QUESTIONNAIRE 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. HEAD TREMOR

Which of the following best describes the amount of head tremor ?

0 - No tremor   

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is intermittent.

4 - Moderate tremor that is present most of the time.

 

2. SPEECH

Which of the following best describes your speech ?

0 - Normal (no unusual symptoms)

1 - Mildly affected (loss of expression, pronunciation and volume)

2 - Moderately affected (monotonous tone, loss of volume, slurring but understandable)

3 - Severely affected (monotonous tone, loss of volume, slurring, difficult to understand)

4 - Unintelligible most of the time

 

3. SALIVATION

Which of the following best describes the amount of saliva produced ?

0 - Normal

1 - Slight but definite excess of saliva in mouth

2 - Moderately excessive saliva with minimal drooling

3 - Marked excess of saliva with some drooling

4 - Almost continuous drooling, requiring continuous attention

 

4. SWALLOWING

Which of the following best describes your ability to swallow ?

0 - Normal

1 - Rare choking

2 - Occasional choking

3 - Requires soft food due to difficulties in swallowing

4 - Requires feeding by artificial means

 

5. FACIAL EXPRESSION

Which of the following best describes your facial expression ?

0 - Normal

1 - Minimal loss of facial expression

2 - Slight but definitely abnormal reduction in facial expression

3 - Moderate loss of facial expression. Lips frequently parted

4 - Severe or complete loss of facial expression. Lips usually significantly parted

 

6. EYE MOVEMENT

Which of the following best describes the movement of your eyes?

0 - Normal

1 - Slight reduction in eye movement and blinking

2 - Distinct reduction in eye movement and blinking

3 - Frequent staring appearance of the eyes

4 - Almost continuous staring appearance of the eyes

 

7. SENSE OF SMELL

Which of the following best describes your sense of smell ?

0 - Normal

1 - Distinctly reduced ability to smell

2 - Unable to smell anything without inhaling

3 - Unable to smell anything, unless inhaling strongly

4 - Unable to smell anything, despite inhaling strongly

 

8. JAW TREMOR

Which of the following best describes the amount of jaw tremor ?

0 - No tremor

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is intermittent.

4 - Moderate tremor that is present most of the time.

 

9. NECK RIGIDITY

Which of the following best describes the amount of rigidity when moving the neck ?

0 - No rigidity

1 - Slight or detectable rigidity

2 - Mild to moderate rigidity

3 - Marked rigidity, but with a full range of motion easily achieved

4 - Severe rigidity. A range of motion is only achieved with difficulty

 

10. RIGHT ARM TREMOR AT REST

Which of the following best describes the right arm at rest ?

0 - Normal

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

11. LEFT ARM TREMOR AT REST

Which of the following best describes the left arm at rest ?

0 - Normal

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

12. RIGHT ARM ACTION TREMOR

Which of the following best describes the right arm whilst being used ?

0 - Normal

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

13. LEFT ARM ACTION TREMOR

Which of the following best describes the left arm whilst being used ?

0 - Normal

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

14. RIGHT HAND RIGIDITY

Which of the following best describes the amount of rigidity when moving the arms ?

0 - No rigidity

1 - Slight or detectable rigidity

2 - Mild to moderate rigidity

3 - Marked rigidity, but with a full range of motion easily achieved

4 - Severe rigidity. A range of motion is only achieved with difficulty

 

15. LEFT HAND RIGIDITY

Which of the following best describes the amount of rigidity when moving the arms ?

0 - No rigidity

1 - Slight or detectable rigidity

2 - Mild to moderate rigidity

3 - Marked rigidity, but with a full range of motion easily achieved

4 - Severe rigidity. A range of motion is only achieved with difficulty

 

16. RIGHT HAND TREMOR

Which of the following best describes the amount of tremor in the right hand ?

0 - No tremor

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

17. LEFT HAND TREMOR

Which of the following best describes the amount of tremor in the left hand ?

0 - No tremor

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

18. RIGHT HAND FINGER RIGIDITY

Which of the following best describes the fingers of the right hand when they tap on a surface ?

0 - Normal

1 - Mild slowing or reduction in magnitude

2 - Moderately impaired. Definite and early fatiguing. Occasionally ceases movement

3 - Severely impaired. Frequent hesitation or cessation of movement

4 - Can barely perform the task

 

19. LEFT HAND FINGER RIGIDITY

Which of the following best describes the fingers of the right hand when they tap on a surface ?

0 - Normal

1 - Mild slowing or reduction in magnitude

2 - Moderately impaired. Definite and early fatiguing. Occasionally ceases movement

3 - Severely impaired. Frequent hesitation or cessation of movement

4 - Can barely perform the task

 

20. RIGHT HAND RIGIDITY

Which of the following best describes what happens when you open and close your right hand in rapid succession ?

0 - Normal

1 - Mild slowing or reduction in magnitude

2 - Moderately impaired. Definite and early fatiguing. Occasionally ceases movement

3 - Severely impaired. Frequent hesitation or cessation of movement

4 - Can barely perform the task

 

21. LEFT HAND RIGIDITY

Which of the following best describes what happens when you open and close your left hand in rapid succession ?

0 - Normal

1 - Mild slowing or reduction in magnitude

2 - Moderately impaired. Definite and early fatiguing. Occasionally ceases movement

3 - Severely impaired. Frequent hesitation or cessation of movement

4 - Can barely perform the task

 

22. RIGHT LEG TREMOR

Which of the following best describes the amount of tremor in the right leg ?

0 - No tremor

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

23. LEFT LEG TREMOR

Which of the following best describes the amount of tremor in the left leg ?

0 - No tremor

1 - Slight and infrequent tremor

2 - Moderate tremor that is intermittent

3 - Moderate tremor that is present most of the time

4 - Severe tremor that is present most of the time

 

24. BALANCE

On those days that you walk, which of the following best describes the frequency with which you fall due to walking difficulties ?

0 - None

1 - Rarely

2 - Occasionally (less than once per day)

3 - Falls an average of about once daily

4 - Falls more than once daily

 

25. WALKING DIFFICULTIES

which of the following best describes the frequency with which you have to stop walking due to difficulties caused by Parkinson's disease?

0 - Normal

1 - Rarely

2 - Occasionally

3 - Frequently

4 - Unable to walk

 

26. WALKING ABILITY

Which of the following best describes your general ability to walk ?

0 - Normal

1 - Mild difficulty. Walks slowly, and may shuffle with short steps

2 - Moderate difficulty, but requires no assistance. May shuffle or have short steps.

3 - Severe disturbance of walking, requiring assistance.

4 - Cannot walk at all, even with assistance.

 

27. RIGHT FOOT RIGIDITY

Which of the following best describes your ability to tap your right heel on the ground in rapid succession ?

0 - Normal

1 - Mild slowing or reduction in amplitude

2 - Moderately impaired. Occasional hesitation or cessation of movement

3 - Severely impaired. Frequent hesitation or cessation of movement

4 - Can barely perform the task

 

28. LEFT FOOT RIGIDITY

Which of the following best describes your ability to tap your left heel on the ground in rapid succession ?

0 - Normal

1 - Mild slowing or reduction in amplitude

2 - Moderately impaired. Occasional hesitation or cessation of movement

3 - Severely impaired. Frequent hesitation or cessation of movement

4 - Can barely perform the task

 

29. POSTURE

Which of the following best describes your posture ?

0 - Normal

1 - Not quite erect, slightly stooped posture

2 - Moderately stooped posture, definitely abnormal

3 - Severely stooped posture

4 - Marked bending forward of the body with extreme abnormality of posture

 

30. UPPER BODY MOVEMENT

Which of the following best describes your upper body movement ?

0 - Normal

1 - Minimal slowness, giving movement a deliberate character

2 - Mild degree of slowness and lack of movement, which is definitely abnormal

3 - Moderate slowness, and a moderate lack or small amplitude of movement

4 - Marked slowness, and a marked lack or small amplitude of movement

 

31. RESPIRATION

Which of the following best describes your breathing ?

0 - I can hold my breath for more than 20 seconds

1 - I can hold my breath for more than 10 seconds

2 - I can hold my breath for a few seconds

3 - I can not hold my breath but can breath normally

4 - Unable to breath normally

 

32. URINARY FUNCTION

Which of the following best describes your urinary function ?

0 - Normal

1 - Greater urgency to urinate than is justified

2 - Occasionally urinate before going to the toilet

3 - Often urinate before going to the toilet

4 - No control over urination

 

33. CONSTIPATION

Which of the following best describes your bowel function ?

0 - Daily

1 - At least three times a week

2 - Twice a week

3 - Once a week

4 - Bowels unable to function without assistance

 

34. MUSCLE PAIN

Which of the following best describes the general feeling in your muscles ?

0 - Nothing unusual experienced

1 - Occasional numbness, tingling, or mild aching

2 - Frequent numbness, tingling, or mild aching

3 - Frequent painful sensations

4 - Excruciating pain

 

35. MOOD

Which of the following best describes your general mood ?

0 - No sustained periods of depression

1 - Depressed for more than a day at a time but not for several days at a time

2 - Depressed for days or weeks at a time

3 - Continuous depression

4 -Continuous depression. Frequent suicidal thoughts or intent.

 

36. MOTIVATION

Which of the following best describes your level of motivation ?

0 - Fairly normal level of motivation

1 - Distinctly less motivation and more passive than the average person

2 - Loss of initiative or disinterest in non-routine activities

3 - Loss of initiative or disinterest in day to day (routine) activities.

4 - Complete loss of motivation

   

 

 
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