IS DBS THERAPY RIGHT FOR ME?
THANK YOU FOR TAKING THE TIME TO ASSESS YOUR SUITABILITY FOR DBS. THIS QUESTIONNAIRE SHOULD TAKE ABOUT 10 MINUTES TO COMPLETE. PLEASE FIND BELOW SOME GUIDANCE RELATED TO THE QUESTIONNAIRE BEFORE PROCEEDING.
STEP 1. ABOUT YOU
How old are you?
STEP 2. YOUR PARKINSON’S
Do you have symptoms which are bothersome to you i.e. interfering with your day-to-day activities?
STEP 3. YOUR MOTOR OR PHYSICAL SYMPTOMS
How would you rate symptoms that re-emerge before your next medication dose is due?
How would you describe any involuntary, incontrollable and unintended movements (dyskinesias) you experience which affect your daily activities?
How would you describe any tremor you experience that interferes with your quality of life?
Do you have trouble walking without a walking aid such as a stick or cane, even once you have taken your medication?
Do you feel stiff when you walk, rather like a robot walks, even if you have taken your medication?
Does it sometimes feel like your feet are stuck to the floor?
Have you had any falls in the last three months?
STEP 4. YOUR NON-MOTOR OR NON-PHYSICAL SYMPTOMS
Do you have difficulty thinking clearly and/or problems with your memory or concentration?
Have you lost interest in things you would usually enjoy?
Do you sometimes feel life is hopeless?
Do you experience symptoms triggered by your Parkinson’s medication such as hallucinations, nausea, sleep problems, diarrhoea, dizziness, gambling, hyper-sexuality, hypomania?
STEP 5. OTHER CONSIDERATIONS TO DISCUSS WITH YOUR NURSE OR DOCTOR
Is it getting harder to do what you want to do at home, at work and in your leisure time?
Do you avoid conversations or talking on the phone because of speech concerns?
Do you need to urinate frequently?
Do you experience constipation?
Do you have an increased interest in, or difficulty having sex?
In the morning, does it take more than 20 minutes for your medication to start working?
Use this space to make notes to help you remember any other points you would like to discuss with your doctor.
Something I want to tell my doctor today
Something I learned about DBS that I want to clarify with my doctor
REPORT FOR MY PARKINSON’S CHECKUP
Thank you for completing the questionnaire. Based on your answers it is unclear if DBS is a good option for you. Please discuss this assessment and your options with your doctor.
Thank you for completing the questionnaire. Based on your answers we recommend that you ask your doctor about DBS therapy.
Thank you for completing the questionnaire. Based on your answers we strongly recommend that you ask your doctor about DBS therapy.