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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