Individuals with Parkinson’s Disease


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Personal Information
First Name
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Last Name
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Date of Birth
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Marital Status
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Name (Spouse/Partner)
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Date of Birth (Spouse/Partner)
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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1. Do you currently need or receive assistance or supervision performing everyday living activities, such as walking, bathing, dressing, eating, transferring or toileting?
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2. Are you currently confined to a hospital, nursing home,
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3. Do you use oxygen continuously or a walker,
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4. Have you ever been diagnosed with or treated for
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Mental Retardation, Alzheimer's Disease, Dementia, Senility or any type of Organic Brain Syndrome or Disorder, Schizophrenia, or consulted a physician about memory loss, forgetfulness or confusion?
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Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related Complex (ARC), or tested positive for the Human Immunodeficiency Virus (HIV)?
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ALS (Amyotrophic Lateral Sclerosis or Lou Gehring's Disease), Cerebral Palsy, Charcot Marie Tooth, Cystic Fibrosis or Muscular Dystrophy?
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Have you ever tested positive for Huntington's Chorea?
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How did you hear about us?
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Additional Comments
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