Live Well With Parkinson's

1. Do you or your spouse/partner/family member have Parkinson's Disease?

Yes
No

This is a required question

2. Are you a:

Person with Parkinson's (PwP)
Partner/spouse/family member of a PwP*

This is a required question

3. Are you:

Male
Female

This is a required question

5. How long have you lived with Parkinson's?

This is a required question

6. How much assistance do you require with personal care or daily activities?

	1	2	3	4	5
						Full Assistance

This is a required question

7. Do you take medications for Parkinson's disease?

Yes
No

This is a required question

10. Do you take your medications at specific times in the day?

Yes
No

This is a required question

11. Do you experience the "wearing-off" of the effects of medication prior to the next dose?

("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

This is a required question

12. How often do you stick to a medication schedule?

Never
Sometimes
Most of the time
Always

This is a required question

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:

This is a required question

14. Would you be interested in using an electronic form of a medication tool?

(This tool can help you schedule your medications and your meals customized to your individual lifestyle preferences.)

Yes
No
Undecided

This is a required question

15. Do you take l-dopa with meals?

Yes
No

This is a required question

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

This is a required question

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?

(A "protein redistribution diet" involves eating low protein during the day and high protein in the evening.)

Yes
No

This is a required question

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

This is a required question

19. What kind of foods would you like to see included in recipes?

This is a required question

20. Which health care providers manage your Parkinson's?

Select all that apply.

General Practitioner
Neurologist
Movement Disorder Specialist
Other:

This is a required question

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

Please enter one response per row

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

This is a required question

24. Would you use a website that offered practical strategies to living with Parkinson's?

Yes
No
Unsure

This is a required question

25. Do you have any additional comments you would like to add?

This is a required question

	0	1	2	3	4	5
							Excellent Control