Dear Edith,

I think the idea is great and was thinking of posting a simple questionnaire
to the group myself to do a basic analysis. Here's my first draft.

Feel free to comment and add/change.

Best wishes,
Marco
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PIENO Member study questionnaire - v1.0 May 8, 2001
____________________________________________________________________________
_________________

Gender       -    |M/F| (delete one)

Age            -    |    | (at time of last birthday)

Marital status   |S/M/W/D| Single/Married/Widowed/Divorced

Relationship1   |   | rate relationship 1-10 before onset of PD

Relationship 2   |   | rate relationship 1-10 since onset of PD

Sex 1               |   | rate sex relationship 1-10 before onset of PD

Sex 2               |   | rate sex relationship 1-10 since onset of PD

Children      -   |Y/N|

PD since     -    mm/yyyy

PD Dxd      -    mm/yyyy

PD family hist - |Y/N|
                        y=|P/M| Paternal/Maternal, |  |generation, |
|relationship:Parent/GParent/GGParent/Uncle/Aunt/Cousin

Pallidotomy -   |Y/N|
                       |mm/yyyy|

DBS           -   |Y/N|
                   -   |mm/yyyy|

PD Meds1.-   What  |                               |
                       Dose  |    |
                       from   |mm/yyyy|
                       implvl |   | on a scale of 1-10, rate improvement
level
                       s/effects|list
| e.g. nausea, dyskinesia, hallucination, insomia

PD Meds2.-   What  |                               |
                       Dose  |    |
                       from   |mm/yyyy|
                       implvl |   | on a scale of 1-10, rate improvement
level
                       s/effects|list
| e.g. nausea, dyskinesia, hallucination, insomia

PD Meds3.-   What  |                               |
                       Dose  |    |
                       from   |mm/yyyy|
                       implvl |   | on a scale of 1-10, rate improvement
level
                       s/effects|list
| e.g. nausea, dyskinesia, hallucination, insomia

Birth          -    Normal, Complex, C-section, |N/C/Cs|
                 -    Induced |Y/N|
                 -    Epidural |Y/N|
                 -    Gen. A  | Y/N|
                -     Home/Hospital/Other|H/Hs/O|

Location    -    At birth
                       Proximaty to Heavy Inds. complex: |Y/N|
                       Y= <5miles|  |5-10miles|  | >10miles|  |

Location -       At current
                       Proximaty to Heavy Inds. complex:  |Y/N|
                       Y= <5miles|  |5-10miles|  | >10miles|  |

Occupation-    At present
                  -    At last
                  -    history
Exp Tox sub  - |Y/N|
                        Y= what|                 | where|
|when|                      |duration|                    |frequency|
|
                                (LIST ALL, industrial,
agricultural(nitrates, phosphates & pesticides) etc.)

Miliary Svc - home |Y/N
                     fr-to  |mm/yyyy-mm/yyyy|
                     exp   |Y/N| to radioactive materials
                     exp   |Y/N| to dangerous chemicals

                  - O'seas
                     fr-to  |mm/yyyy-mm/yyyy|
                     exp   |Y/N| to radioactive materials
                     exp   |Y/N| to dangerous chemicals

                  - Combat
                     fr-to  |mm/yyyy-mm/yyyy|
                     exp   |Y/N| to radioactive materials
                     exp   |Y/N| to dangerous chemicals

Serious illness - 1) |                                           |
               from-to  |mm/yyyy-mm/yyyy|
               Med's    |                            |
                Dose    |       |

 Serious illness - 2) |                                           |
               from-to  |mm/yyyy-mm/yyyy|
               Med's    |                            |
                Dose     |      |

Serious illness - 3) |                                           |
               from-to  |mm/yyyy-mm/yyyy|
               Med's    |                            |
                Dose    |       |


Clinical Dep.   -     |Y/N|
from-to                  |mm/yyyy-mm/yyyy|
Medication      -     |                             |

Accidents to Head  |Y/N|

Anxiety                   |Y/N|

Vitamin supp's         |Y/N|
                               |Y=list|

Homoaeopathy        |Y/N|

Complimentary        |Y/N| e.g Reflexology, Reiki

Exercise                  |Y/N| y=list

Diet                         Dairy
                                Meat
                                Fish
                                 Fruit
                                 Vegetables
                                   Cereals
                                 Pulses

Breakfast                   |Y/N| y=simple/medium/full

Lunch                         |Y/N| y=light/full

Dinner/Evening            |Y/N| y=light/full

Water                         |Y/N| y=how many glass's per day

Wine red                        |Y/N| y=how much per week

Wine white                     |Y/N| y=how much per week

Beer                            |Y/N| y=how much per week

Cigarettes                        |Y/N| y=how many per week

Cigars                        |Y/N| y=how many per week

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