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:



□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

□Balance problems

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

□Swallowing problems

□Communication and Speech difficulties





□Apathy or trouble self- initiating tasks

□Bladder problems


□Cognitive Problems 


□Memory Problems or Mild thinking difficulties


□Hallucinations or sensitivity to hallucinations with certain medicines





□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



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


Monique Giroux, MD ©DrGiroux2014