PPG Fitness for Parkinson's Participant Questionnaire
Thank you for taking the time to answer the following questions to help us make Ping Pong Fitness for Parkinson's the best program it can be. Your answers will be strictly confidential. They will be used to ensure your safety and assist in further program development.
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Email *
PPG Fitness Location: *
Required
First Name:  *
Last Name *
Date: *
Have you been diagnosed with any medical problems or physical limitations besides Parkinson's that we should be aware of? *
What is your dominant hand? *
What side is most impacted? *
Estimated date of PD diagnosis? *
Do you have periods when your medication is less effective ("off periods")? If so, how frequently and for what duration? (For example, 1x/day, 2-3x/week, monthly) *
Do you experience any of the following symptoms? (check all that apply) *
Required
Do you: (check all that apply) *
Required
Do you have a history of falls?  *
If you have a history of falls, how many have you had in the last 6 months? If none, answer NONE. *
Do you take medicine for Parkinson's? If yes, please list: *
To establish the criteria for a research study and track the benefits of playing ping pong, we ask participants to answer the Parkinson's Disease Quality of Life Questionnaire (PDQ-39). If you are willing to do so, please indicate below, and it will be provided to you separately. *
A copy of your responses will be emailed to the address you provided.
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