Patient's state of residence Please select...
AL
AK
AS
AZ
AR
AA
AE
AP
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
FM
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
What is the patient's current living situation? (Select one) Please select...
Live alone
Live with a caregiver
Live in an assisted living facility
Other (please specify)
Patient's Birth Month Please select...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Patient's Birth Day Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Patient's Birth Year Please select...
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Is the patient a U.S. military veteran or military service member? Please select...
Yes, they are a military veteran
Yes, they are currently serving in the military
No
In the past year, how often has the Parkinson's patient seen their Parkinson's care provider? Please select...
Zero
1 time
2 times
Greater than 2 times
In the past year, how satisfied were you and/or the Parkinson's patient with their access to Parkinson's health care services? Please select...
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
In the past year, has your and/or the Parkinson's patient's satisfaction with Parkinson's care services changed and if so, in what way? Please select...
Yes, it has improved significantly
Yes, it has improved somewhat
No, it has remained the same
Yes, it has worsened somewhat
Yes, it has worsened significantly
Not applicable/the Parkinson’s patient does not use Parkinson's care services
Not sure
How has this change affected the Parkinson's patient's ability to get the care they need? Please select...
Much easier
Somewhat easier
No change
Somewhat harder
Much harder
In the past year, has the Parkinson's patient experienced any unplanned changes with their insurance coverage? Please select...
Yes
No
I’m not sure
If you answered 'yes,' please explain. If you know the reason(s) the patient's insurance coverage has changed, please include those in your explanation.
Does the Parkinson's patient receive long-term care insurance benefits? Please select...
Yes
No
If you answered 'yes,' has the patient experienced any unplanned changes in reimbursements or access to this insurance coverage in the past year? If so, please explain.
Does the Parkinson's patient receive long-term care services in a facility, at home or in the community? Please select...
Yes
No
Does the Parkinson's patient receive benefits from the Social Security Administration including Social Security retirement benefits, Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI)? Please select...
Yes
No
If you answered 'yes,' has the patient experienced any unplanned changes in monthly benefit payments or reimbursements in the past year? If so, please explain.
Does the Parkinson's patient use telehealth? Please select...
Yes
No
If you answered 'yes,' has the patient experienced any unplanned changes in telehealth reimbursements or access to care in the past year? If so, please explain.
Do you and/or the Parkinson's patient currently participate in Parkinson's disease clinical research studies? Please select...
Yes
No
If you answered 'yes,' have these studies changed in any way in the past year?
If you or the patient do not participate in Parkinson's clinical research studies, how interested are either of you in participating in the future? Please select...
Very interested
Somewhat interested
Neutral
Not very interested
Not at all interested
Not applicable
If the Parkinson's patient is a military veteran receiving care through the U.S. Department of Veterans Affairs (VA), have they experienced any unplanned changes to their access to care in the past year? Please select...
Yes
No
Not a military veteran
If you answered 'yes,' please explain. If you know the reason(s) their VA care has changed, please include those in your explanation.
If the Parkinson's patient is a military veteran, do they receive care or services at a Parkinson's Disease Research, Education and Clinical Centers (PADRECCs) or affiliated program operated by the VA? Please select...
Yes
No
Not a military veteran
If you answered 'yes,' has the patient experienced any unplanned changes in reimbursements or access to care at these programs in the past year? If so, please explain.
Has the price of the patient's Parkinson's prescription medications changed in the past year? Please select...
Yes
No
Not applicable
If you answered 'yes,' please explain. If you know the reason(s) for the price change(s), please include those in your explanation.
Have you experienced any unplanned changes in programs that provide resources or financial assistance to caregivers or care partners in the past year(including but not limited to respite care, Medicaid reimbursement, paid family leave, local agencies on aging programs, veterans' programs and long-term care insurance policies)? Please select...
Yes
No
Not applicable
If you answered 'yes,' please explain. If you know the reason(s) for the changes to these programs, please include those in your explanation.
Are there other ways the patient's Parkinson's care has changed in the past year? Please select...
Yes
No
If you answered 'yes,' please explain.