General Characteristics:

• Time of Onset: Age of onset

• Initial symptoms (laterality): Tremor, dystonia, gait disturbance, falls, orthostatic hypotension, vision changes

• Prodromal symptoms: Constipation, anosmia/hyposmia, REM sleep behavior disorder, etc

• Motor Symptoms: Tremor, dystonia, myoclonus, dyskinesias, myoclonus, falls, postural instability, freezing

• Non-motor symptoms: Constipation, cognitive changes, depression/anxiety, hallucinations, dysphagia, speech abnormalities, urinary retention/urgency, hyper/hypohydrosis, sialorrhea, vision changes, sexual dysfunction, pain

• Progression of the disease: Worsening or new symptoms over time

• Trial of levodopa: Helpful or unhelpful for management of symptoms

• Family history of Parkinsonism: PD, multiple systems atrophy (MSA), Progressive Supranuclear Palsy (PSP), etc

Management:

• Prior medications: Current medications

• Deep Brain Stimulation: If present, time of surgery and efficacy

• Dopamine side effects: hallucinations, impulse control disorder, sleep attacks, obsessive/compulsive behaviors, worsening orthostatic hypotension

• Response to medication:

  • Medication onset: How many minutes after starting medication does the patient notice improvement in symptoms

  • Duration of effect: In hours

  • Wearing off of medication: If yes, how much time prior to next dose

  • Dyskinesias:

  • Amount of time during the day with poor motor function (%): Off times and/or dyskinesias

• Therapy:

  • Last physical therapy visit:

  • Last occupational therapy visit:

  • Last speech pathology visit:

  • Exercise regimen: