Established Parkinsons

Parkinsons is a neurodegenerative disorder with tremor, rigidity, and bradykinesia. It is a clinical diagnosis, but DAT scans can be helpful. Treatment is with dopaminergic agents.

History of Parkinsons
Current out-patient neurologist: _______
Date of PD diagnosis: _______
Date of last office visit: ________
Medication changes made last visit: _______

Medication Management

Current PD medication regimen

Carbidopa-levodopa (Sinemet): Specify frequency and time of day taken (must be taken >30min before meals and without protein

Pramipexole (Mirapex)

Apomorphine (Apokyn)

Rotigotine (Neupro)

Selegiline (Zelapar)

Rasagiline (Azilect)

Safinamide (Xadago)

Entacapone (Comtan)

Opicapone (Ongentys)

Bentropine (Cogentin)

Trihexyphenidyl

Amantadine

Pimavanserin (Nuplazid)

Other

PD medications tried in the past

Carbidopa-levodopa (Sinemet)

Pramipexole (Mirapex)

Apomorphine (Apokyn)

Rotigotine (Neupro)

Selegiline (Zelapar)

Rasagiline (Azilect)

Safinamide (Xadago)

Entacapone (Comtan)

Opicapone (Ongentys)

Bentropine (Cogentin)

Trihexyphenidyl

Amantadine

Pimavanserin (Nuplazid)

Other

Medication-related side effects

Nausea

Orthostatic hypotension

Disinhibition

Hallucinations

Fatigue

Dyskinesia

Diarrhea

Constipation

Confusion

Dry mouth

Impaired urination

Livedo retiularis

Patient notices medication wearing off (effect diminishes prior to next dose)

Peak-dose dyskinesias present (2 hours post-dose, involuntary movements of the extremities, head, face, trunk)

Dyskinesias are functionally limiting

Screen medications for polypharmacy and medications that may exacerbate PD (i.e. neuroleptics) this visit

Motor Features

Bradykinesia (slowness of movements, slowed reaction time, takes longer to carry out tasks)

Hypokinesia (decreased amplitude of movements e.g. micrographia, small steps)

Akinesia (delayed movement initiation reduced frequency of spontaneous movements)

Rigidity (stiffness, pain, particularly in shoulder)

Freezing of gait or feeling stuck

Postural instability

Falls (specify frequency and severity)

Uses ambulation aides (specify types and duration)

Dystonia (often in the morning upon awakening, commonly involving foot)

Severe neck flexion (dropped head)

Severe truncal flexion (camptocormia)

Hypophonia

Hypomimia

Tremor
Location

Head

Voice

Chin

Extremities

Lateralization

Right

Left

Bilateral

Type

Rest

Action

Non-motor Features

Positional dizziness or Orthostatic hypotension

Urinary or Fecal Incontinence

Sexual dysfunction

Increased sweating

Dysphagia

Drooling

Sleep disturbance

Insomnia

Sleep attacks

Sleep apnea

REM behavioral disorders

Restless leg syndrome

Anosmia

Constipation

Unable to perform ADLs

Unable to perform IADLs

Pain

Unexplained pain

Musculoskeletal pain

Dystonic pain

Central pain

Neuropathic pain

Mood and Cognition

Depression

Anxiety

Memory loss

Hallucination

Delusions

Compulsivity or Impulsivity

Prior Workup

Vascular risk factor assessment completed

Brain or spine imaging performed

Formal neuro-psychologic testing

Speech/PT/OT evaluation

Are memory symptoms present? If yes, has pt had a workup for treatable causes of memory impairment?

TSH

Vitamin deficiency

HIV

Syphilis

OSA screen

Established Parkinsons

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