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Parkinson's Disease Survey
Thank you very much for taking the time to complete this important survey.
*
Indicates required field
How old are you?
*
Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
What is your gender?
*
Male
Female
What is your ethnicity?
*
Caucasion/white
African American/black
Hispanic/Latin American
Asian
Middle eastern
Native American
Other
None
When were you diagnosed with Parkinson's Disease?
*
Are you concerned that you (or your loved one) may lose their balance and/or fall?
*
Yes
No
Have you fallen in the last year?
*
Yes
No
Have you fallen in the last month?
*
Yes
No
How many times have you fallen in the last year?
*
Everyday
at least once per week
2 to 3 times per week
Once per month
Once per six months
More than once per six months
Once per 12 months
Have you participated or tried any balance programs or physical therapy to improve your balance?
*
Yes
No
How would you rate your balance on a scale of 0-10?
*
0-1
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
(0 = worst, 10 = BEST)
Name
*
First
Last
Email
*
Comment
*
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