Date:... ... Time:...
Code-ID:...
Man Woman Length:... Weight:...
Marital status Housing conditions
Single Villa/House
Co-habiting Apartment
Education:
Number of years:... ...
Parkinson's disease
What year were you diagnosed with Parkinson's disease? ...
(Check for idiopathic Parkinson's)
What were your debut symptoms:...
Right Side Left Side
Who is your current neurologist?
...
...
What are your main symptoms of Parkinson's?
...
Past/current diseases
Diabetes No / Yes Duration...
Hypertension No / Yes Duration...
Heart disease No /Yes Duration...
Lung disease No /Yes Duration...
Cancer No /Yes Location………
Time of diagnoses………….
Other neurological disease No /Yes Detail...
...
Joint disease (Osteoarthritis, RA) No/ Yes Location……….
Duration………..
Previous fracture No /Yes Location……….
Year……….
Osteoporosis No /Yes Duration………..
Vision Good Impaired
Glasses Cateract Undergone surgery
Hearing Good Impaired
Uses hearing aids
Other illness/injury or pain... ...
Do you have a memory problem? No Yes
What kind of problem/ how does this affect you?...
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Do you feel that your health condition has changed as a result of the Corona pandemic?
Yes No
If yes, has your health status Improved Deteriorated
Can you describe this change……….
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Do you think you've had Covid-19? Yes No
If yes, during what time period were you sick? ... To...
Have you been tested for the disease? Yes No
If yes, Tested positive Tested negative
Current medication (Ask for and medications daily doses (mg))
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Fall
Fallen: No Yes Number of times last: 6 months... ...12 months...
Fear of falls: No Yes A little Moderate Much
Walking aids: No Yes Type, indoors and/or outdoors... ...
Other aids: No Yes Which... ...
Current exercise habits
Note all forms of physical exercise that the person performs. Also
note
frequency (number of times per week), length (number of minutes per time) anddegree of
exertion (they become sweaty, breathless, etc.). Also ask about housework and gardening in order to assess Frändin Grimby.………
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How physically active are you right now? (Frändin-Grimby scale)
1. Hardly any physical activity.
2. Mostly sitting, sometimes walking, light gardening, sometimes light domestic work such as heating food, dusting.
3. Light physical activity about 2-4 hours per week such as walking, fishing, dancing, gardening, walking to and from the shop. The main responsibility for lighter
home work such as cooking, damning, "removing" and making beds. Perform or take part in weekly cleaning.
4. Moderate physical activity 1-2 hours per week such as jogging, swimming, gymnastics, heavier gardening, cooking at home or light physical activity
more than 4 hours per week. The main responsibility for all housework, easy as well as heavy. Weekly cleaning with vacuuming, floor wash and window cleaner.
5. Moderate physical activity 3 hours per week such as tennis, swimming, jogging etc.
6. Hard or very hard physical activity regularly and several times per week, where the physical effort is great such as jogging and skiing.
Have your exercise/physical activity habits changed due to the Covid-19 epidemic/ advice from authorities or healthcare recommendations ? Yes No
Do you move less outdoors? Yes No
Do you take fewer and/ or shorter walks? Yes No
Do you go to organized training (e.g. gym/pool/group training)
to a lesser extent? Yes No
Have you missed planned rehabilitation because it has been cancelled
or that you have chosen not to go? Yes No
Do you use digital services (such as a mobile app) for
physical activity/exercise/exercise? Yes No
if yes, you have started to use the digital service as a result of
of the current situation with the Covid-19 epidemic? Yes No
Free text (Other info e.g. motivation)
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