Northwest Parkinson's Foundation

Parkinson’s Symptom Summary

Name: _______________________________ Date: ______________

The following checklist can be provided to other medical specialists, therapists or
your hospital team to optimize your care.

I have trouble in the following areas that may be affected by my treatment,
hospital stay or procedure:

Motor

□Tremor


□Dyskinesia - uncontrollable movements usually caused by medicine


□ ‘On-off’ fluctuations - periods of time when my medicines are working (‘on’) that I can move better and when my medicines are not working (‘off’) and I have difficulty moving. ‘Off’ periods are usually end of dose so I must get my medicines On time. I MUST HAVE MY PD MEDICINES ON TIME TO REDUCE THIS PROBLEM


□Dystonia - involuntary muscle spasm, contraction leading to pain, flexion, or twisting
movements

□Balance problems


□Freezing or gait or motor initiation problems (feet stuck to floor)


□Swallowing problems


□Communication and Speech difficulties

 

Non-motor


□Depression


□Anxiety


□Apathy or trouble self- initiating tasks


□Bladder problems

 

□Cognitive Problems 

 

□Memory Problems or Mild thinking difficulties


□Dementia


□Hallucinations or sensitivity to hallucinations with certain medicines


□Drooling

 


□Fatigue 

 

□Impulsivity Problems


□Loss of Smell or loss of appetite


□Pain: List where on body____________________________


□Sleep Problems 


□Trouble staying asleep


□Restless Legs Syndrome


□Sleep Apnea


□REM Sleep Behavior Disorder: Vivid, active, physical dreaming


□Daytime sleepiness


□Sensations: Tingling, Aches, Pain, Cold Hands/Feet


□Sexual Dysfunction

 

Other:

NWPF mission is to establish optimal quality of life for the Northwest Parkinson’s 
community through awareness, education, advocacy and care. For more information 
please visit nwpf.org.

 

Monique Giroux, MD ©DrGiroux2014