Parkinson's Disease Assessment Form

This form is split into multiple pages, please complete each page using the tabs below before submitting your application on the last page.

At the end of the process you will be given the opportunity to print a copy of the application for your own records.

Alternatively you can download a blank form in word format here

Personal details
Health 1
Health 2
Health 3
Confirmation

Any information entered in this form is held in the stricted confidence and is not shared with any third party.

Personal Details

Name *

Date of birth * (dd/mm/yyyy)

Home address *

Home telephone no *

Mobile telephone no

Email address *

Emergency contact name

Emergency contact relationship

Emergency contact number

Emergency contact mobile

Work telephone no

Occupation

Present or previousYes | No

Hobbies

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Medical Details

GP's Name

GP's Address

Diagnosis

Date of diagnosis (dd/mm/yyyy)

What was the first indication of your problems (when?)

Which side is more affected?

Drug regime (if applicable)

General health (any other problems affecting movements)

Any other drugs taken (please provide details)

Any allergies

Operations? Please provide details

Vision problems

Hearing problems

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Present State of Movements

Have you got any difficulties with the following:

Speech (volume, clarity, rhythm)

Facial expressions (mimics, gestures)

Tremor (details)

Handwriting (size, fluency)

Rigity/stiffness (where)

Dyskenesia (where)

Balance

Falling over (how often)

Rolling over in bed

Getting in and out of bed

Sleeping

Getting up from the floor

Sitting down

Standing up from a chair

Walking

Freezing (how often/when)

Eating

Drinking

Swallowing

Un/dressing (zips/buttons/laces)

Everyday chores

Any other

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Current Treatments

Neurologist

Name

Address

Frequency

PD Nurse

Name

Address

Frequency

Physiotherapy

Name

Address

Frequency/Duration

Speech & Language Therapy

Name

Address

Frequency/Duration

Occupational Therapy

Name

Address

Frequency/Duration

Please scroll back up to the top and complete the form's next page.

Confirmation

I declare that all the information above is true to my best knowledge and I will inform all relevant professional that I will participate in Conductive Education sessions.

Confirm name *

Confirm date * (dd/mm/yyyy)