If your client has a history of Parkinson's Disease, please answer the following :


 Agent Name:  
Client Name: 
Phone:  
Fax: 
   


1.  Date of first diagnosis ? 

2.  Current functional stage of your client ?
       Stage I    unilateral involvement
       Stage II   bilateral involvement but normal stance
       Stage III  bilateral involvement with mild postural imbalance
                     but able to lead an independent life
       Stage IV   bilateral involvement with postural instability,
                     requires substantial help
       Stage V    severe disease; restricted to bed or wheelchair

 3.  Has there been any evidence of progression ? Yes   No If yes, give details: 



 4.  Is your client on any medication ? Yes   No  If yes, give details:



5.  Have any of the following problems ocurred ?
       Dementia
       Memory Problems
       Aspiration
       Recurrent Infections
       Falls
       Recurrent Injuries

 6.  Has your client smoked cigarettes in the last 12 months ? Yes   No 

7.  Does your client have any major health problems ? Yes   No  (example: cancer, etc.)
 If yes, give details: