Parkinson’s Disease

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Parkinson’s Disease Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date of diagnosis:
MM slash DD slash YYYY
Note the current functional stage of the 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
Has there been any evidence of progression?
- Yes
- No
If yes, provide details:
Have any of the following occurred? (select all that apply)
- Dementia
- Memory problems
- Depression
- Recurrent infections
- Falls
- Recurrent injuries
Is the client independent (could live alone without assistance)?
- Yes
- No
If no, list extent of disability below:
Is the client receiving disability payments due to inability to work full-time?
- Yes
- No
If yes, provide details below.

Medications

Click the + sign to add additional medications.

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

List any other major health problems the client has:
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