Parkinson’s Disease Intake Form – UPDRS Assessment

Part I: Non-Motor Experiences of Daily Living (nM-EDL)
1.1 Cognitive Impairment:
1.2 Hallucinations & Psychosis:
1.3 Depressed Mood:
1.4 Anxious Mood:
1.5 Apathy:
1.6 Dopamine Dysregulation (Impulse Control):
1.7 Sleep Problems:
1.8 Daytime Sleepiness:
1.9 Pain and Other Sensations:
1.10 Urinary Problems:
1.11 Constipation Problems:
1.12 Light Headed on Standing:
1.13 Fatigue:
Part I Subscore: 0 / 52
Part II: Motor Experiences of Daily Living (M-EDL)
2.1 Speech:
2.2 Saliva and Drooling:
2.3 Chewing and Swallowing:
2.4 Eating Tasks (Using Utensils):
2.5 Dressing:
2.6 Hygiene (Bathing, Toileting):
2.7 Handwriting:
2.8 Doing Hobbies and Activities:
2.9 Turning in Bed:
2.10 Tremor (Impact on ADLs):
2.11 Getting Out of Bed/Car/Chair:
2.12 Walking and Balance:
2.13 Freezing of Gait:
Part II Subscore: 0 / 52
Part III: Motor Examination
3.1 Speech:
3.2 Facial Expression:
3.3a Rigidity – Neck:
3.3b Rigidity – Right Upper Limb:
3.3c Rigidity – Left Upper Limb:
3.3d Rigidity – Right Lower Limb:
3.3e Rigidity – Left Lower Limb:
3.4a Finger Taps – Right Hand:
3.4b Finger Taps – Left Hand:
3.5a Hand Movements – Right Hand:
3.5b Hand Movements – Left Hand:
3.6a Rapid Alternating Movement – Right Hand:
3.6b Rapid Alternating Movement – Left Hand:
3.7a Toe Tapping – Right Foot:
3.7b Toe Tapping – Left Foot:
3.8a Leg Agility – Right:
3.8b Leg Agility – Left:
3.9 Arising from Chair:
3.10 Gait:
3.11 Freezing of Gait:
3.12 Postural Stability (Pull Test):
3.13 Posture:
3.14 Global Bradykinesia (Body Bradykinesia):
3.15a Postural Tremor – Right Hand:
3.15b Postural Tremor – Left Hand:
3.16a Kinetic Tremor – Right Hand:
3.16b Kinetic Tremor – Left Hand:
3.17a Rest Tremor Amplitude – Right Upper Limb:
3.17b Rest Tremor Amplitude – Left Upper Limb:
3.17c Rest Tremor Amplitude – Right Lower Limb:
3.17d Rest Tremor Amplitude – Left Lower Limb:
3.17e Rest Tremor Amplitude – Lip/Jaw:
3.18 Constancy of Rest Tremor:
Part III Subscore: 0 / 132
Part IV: Motor Complications
4.1 Time Spent with Dyskinesias (Percent of Day):
4.2 Functional Impact of Dyskinesias:
4.3 Time Spent in OFF State (Percent of Day):
4.4 Functional Impact of OFF-State Fluctuations:
4.5 Complexity of Motor Fluctuations:
4.6 Painful OFF-State Dystonia:
Part IV Subscore: 0 / 24
Total UPDRS Score: 0