Live Well With Parkinson's
http://livewellwithparkinsons.com/
* Required
1. Do you or your spouse/partner/family member have Parkinson's Disease?
*
Yes
No
2. Are you a:
*
Person with Parkinson's (PwP)
Partner/spouse/family member of a PwP*
3. Are you:
*
Male
Female
4. How old are you:
*
Under 40
41-50
51-60
61-70
71 - 80
Over 80
5. How long have you lived with Parkinson's?
*
Less than 1 year
1 to 5 years
6 to 10 years
11 to 14 years
15 to 20 years
More than 21 years
6. How much assistance do you require with personal care or daily activities?
*
No Assistance
1
2
3
4
5
Full Assistance
7. Do you take medications for Parkinson's disease?
*
Yes
No
8. Which medications do you currently take?
*
Select all that apply
L-dopa/carbidopa (Levocarb, Sinemet)
Prolopa
Sinemet CR
Amantidine (Symmetrel)
Pramipexole (Mirapex)
Ropinirole (Requip)
Rotigotine (Neupro)
Rasagaline (Azilect)
Selgeline (Deprenyl, Edepryl)
Trihexiphenydil (Artane)
Entacapone (Comtan)
Stalevo
Other:
Required
9. Are you satisfied with how your medications control your symptoms of Parkinson's?
*
Not at all
0
1
2
3
4
5
Excellent Control
10. Do you take your medications at specific times in the day?
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Yes
No
11. Do you experience the "wearing-off" of the effects of medication prior to the next dose?
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("Wearing-off" refers to Parkinson's symptoms that re-emerge or worsen before the next dose of l-dopa is due.)
None
Once in a while
Often
Always
12. How often do you stick to a medication schedule?
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Never
Sometimes
Most of the time
Always
13. If you have trouble sticking to a schedule, what are the causes?
*
Select all that apply
Forget to take
Didn't know a schedule was needed
Too difficult to follow schedule
Other:
Required
14. Would you be interested in using an electronic form of a medication tool?
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(This tool can help you schedule your medications and your meals customized to your individual lifestyle preferences.)
Yes
No
Undecided
15. Do you take l-dopa with meals?
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Yes
No
16. Are you aware that eating protein at the same time as taking l-dopa decreases the effectiveness of l-dopa in controlling symptoms?
*
Yes
No
Unsure
17. Are you aware that following a "protein redistribution diet" as part of a lifestyle strategy can improve the effectiveness of l-dopa for symptom control?
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(A "protein redistribution diet" involves eating low protein during the day and high protein in the evening.)
Yes
No
18. Would you consider adopting a protein redistribution diet if you had access to low protein recipes that tasted good and are simple to make?
*
Yes
No
Unsure
19. What kind of foods would you like to see included in recipes?
Your answer
20. Which health care providers manage your Parkinson's?
*
Select all that apply.
General Practitioner
Neurologist
Movement Disorder Specialist
Other:
Required
21. Where do you currently get information regarding Parkinson's?
*
Select all that apply.
Books
Internet
Television
Support groups
Parkinson's organizations
Doctor
Smartphone/Tablets
Brochures
Other health professionals (pharmacist, nurse, other therapists)
Other:
Required
22. How do you prefer to access information regarding Parkinson's?
*
1 (least preferred)
2
3
4
5 (most preferred)
Books
Internet
Television
Support groups
Parkinson's organizations
Doctor
Smartphone/Tablets
Brochures
Other health care professionals
1 (least preferred)
2
3
4
5 (most preferred)
Books
Internet
Television
Support groups
Parkinson's organizations
Doctor
Smartphone/Tablets
Brochures
Other health care professionals
23. What information about living with Parkinson's would you like to know more about?
*
Recognizing symptoms of Parkinson’s
Managing non-movement symptoms (example: mood, thinking, bowel and bladder symptoms)
Medications, side-effects and medication interactions
Tips on self-management (exercise programs, dietary strategies, etc)
Government agencies
Community resources
Local medical and health provider listings
Recent research related to Parkinson’s
Required
24. Would you use a website that offered practical strategies to living with Parkinson's?
*
Yes
No
Unsure
25. Do you have any additional comments you would like to add?
Your answer
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