See If You May Qualify


To determine if you, or your loved one, may qualify for this study it is necessary to ask some medical questions. Please be assured that all information you provide will only be used to determine eligibility for this clinical study. If your answers show that you or your loved one may be a candidate for screening, your information will be forwarded to the research staff so they can contact you.


The survey is brief and should take only a few minutes to complete.




1. Are you the patient, or are you completing this survey on behalf of the patient?

 


2. How did you hear about this clinical research opportunity?










3. Please enter your, or your loved one's, date of birth.
MM/DD/YYYY  


DIAGNOSIS


4. Have you, or has your loved one, been diagnosed by a physician with Parkinson's disease?

 


5. Have you, or has your loved one, experienced the following motor symptoms of Parkinson's disease?



 


6. Have you, or has your loved one, had the motor symptoms you indicated (resting tremor, rigidity or bradykinesia) for 5 years or longer?

 


MEDICATIONS/THERAPY


7. Are you, or is your loved one, currently taking any medications for Parkinson’s disease?

 


8. Did you, or your loved one, notice any symptom improvement as a result of the Parkinson’s disease medication?

 


9. Have you, or has your loved one, used the medication carbidopa/levodopa or a dopamine agonist, such as bromocriptine mesylate, cabergoline, pergolide mesylate, pramipexole, or ropinirole hydrochloride?

 


10. Do you, or your loved one, take medication for depression?

 


MEDICAL HISTORY


11. Have you, or has your loved one, had a prior movement disorder treatment that required brain surgery or device implants?

 


12. Do you, or does your loved one, have an implant:




 


13. Do you, or does your loved one, have a history of recurrent or unprovoked seizures or stroke?

 


14. As part of the study would you, or your loved one, be willing to complete a diary to track your symptoms?