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Name  :
Address :

Age :

Sex Occupation
Telephone No. :
Fax :
Email :
Symptoms:
Tremors:
Slowed Movement:
         Rigidity Stiffness:   
Micrographia:
                        Speech:   
Reduced from
swings:
               Gait Problem:   
Short stepped:
               Shuffling Leg:  
Difficulty in
Getting Up:
                     Joint Pain:  
Postural
Instability:
Eye Blinking:
   Dryness    Itching  
Problem of
Swallowing Food:
Sleep Disorders
Difficulty in Sleep         Pain during Sleep:
Nighttime
Urination:
                  Nightmares:
Rapid or Pounding Heart:
Dryness of Skin:
Problem with
Memory
Confusion:
           Mood Changes:  
Depression:
                      Sadness:  
Nausea:
Heartburn:
Loss of Appetite
Constipation:
                  Dry Mouth:  
Sexual Dysfunction:
History including medical and surgical:

Present Complaints:

Symptoms, Duration and Previous Diagnosis:
Habits:
 Alcohol Smoking Tobacco Drugs 

Other Habits

Non Vegetarian Vegetarian

Family History and Other Investigations:

Diabetes, Hypertension - CNS findings in brief (Muscle Tone, Power, Reflexes, Involuntary Movement):

Difficulty in achieving and maintaining an erection?
Prostate:
               Thyroid
Fatigue:
Weight loss:
Current Medications:
   
         


  Also Download UNIFIED PARKINSON'S DISEASE RATING SCALE form and send it us by email.