Share your Unique Parkinson’s Profile below to Unlock your Free Health Consultation with me. Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Year of Parkinson’s Diagnosis Describe your current physical activity level: * Sedentary Light Moderate Active Motor symptoms * Please indicate what symptoms have you been experiencing: Rigidity Bradykinesia (slow movements) Tremor Gait impairments (walking difficulties) Freezing of gait Speech and voice problems Dyskinesia Muscle pain and/or crumps Other Motor Symptoms: * Please specify all: Cognitive symptoms * Please indicate what symptoms have you been experiencing: Focus and concentration difficulties Memory impairments Hallucinations Decision making difficulty Learning problems Other Cognitive Symptoms: * Please specify all: Mood symptoms * Please indicate what symptoms have you been experiencing: Depression Anxiety Apathy Lack of motivation Isolation Addictive behaviours Other Mood Symptoms: * Please specify all: Current Stage of Parkinson's: * Stage 1: Mild symptoms that generally do not interfere with daily activities. Tremor and other movement symptoms occur on one side of the body only. Changes in posture, walking and facial expressions occur. Stage 2: Worsening of symptoms. Tremor, rigidity and other movement symptoms affect both sides of the body or the midline (e.g. neck, trunk). Walking problems and impaired posture can manifest. Autonomy and independence are still preserved, but daily tasks become more difficult. Stage 3: often named mid-stage; balance become very severe, falls are frequent. Motor symptoms continue to worsen. Functionality is limited, but the person is still physically capable of leading an independent life. Disability is mild to moderate at this stage. Stage 4: Symptoms are fully developed, troublesome and severely disabling. The person is still able to walk alone only if using a walking aid (e.g. cane, walker, etc.) The person needs constant help in daily life and cannot live alone. Stage 5: This is the most severe and debilitating stage. It is almost impossible for the persons to stand or walk. The person is confined to a wheelchair unless assisted. Have you undergone any Parkinson’s-related surgeries? (e.g., DBS) Yes/No. If yes, please specify when and what were the primary symptoms you undergone the surgery for. Have you been diagnosed with any other medical condition? * Yes/No. If yes, please specify: What motivated you to explore the Parkinson Power Protocol? * What are your primary goals in joining the PPP? * (Check all that apply) Improve Strength and Agility Manage Symptoms More Effectively Increase Energy Levels Enhance Mental Well-being Learn about Parkinson’s Care Strategies Learn about functional nutrition and nutraceuticals for PD Improve Mobility and Flexbility Manage Muscle Crumps Manage Fatigue, Pain and Motivation Join a multidisciplinary and holistic method Explore Art Interventions for PD (drama and theatre, ballet, music) Improve Speech and/or Voice symptoms Precise and clear training guidelines with a personal coaching plan Monitored and tracked program All of the above Do you have another goal in joining the PPP? How many hours per week can you dedicate to the program? Please note that PPP is designed as an almost daily training regime, with disciplines varying from integrated Physical Exercising, to NeuroBallet, to PowerBoxing, and Theatre Power Speaking. Hybrid combinations are possible (e.g. in person and home-based services), but need to be discussed with the Head Trainer. Preferred Time for Activities and Consultations: Morning Afternoon Evening Have you participated in any structured exercise or wellness programs before? Yes/No. If yes, please provide details: Are you comfortable with using technology (apps, online forms) for tracking your progress? Yes No Is there anything else you would like us to know about your current situation or expectations? What are the primary service of PPP you would like to join? * Strength and Power Functional High Intensity Training NeuroBallet PowerBoxing Parkinson Meal Plan & Nutraceutical Synergies Mobility and Stretching Training Neurofeedback Techniques Theatre Power Speaking Music Interventions All of them Mindset & Lifestyle Coaching * As we train our bodies, we need to train our minds, too. Would you be interested in a personal mental and mindset coaching program? The added value of our PPP collaboration is a service delivered by a young and motivated Certified Mental & Lifestyle Coach, himself diagnosed with PD. Nobody knows better what you are going through... Yes, I want to know more. No, I am not interested. Additional symptoms you have been experiencing: Sleep problems Constipations Digestive problems Emotional fluctuations Symptoms due to other comorbidities Behavioural changes Data Privacy and Confidentiality * The required information of this questionnaire are treated with complete privacy and used exclusively by the Head Trainer to design the intake session and potential PPP plan for the client. No information will be shared to third parties. After the intake session, the information will be stored only confidentially and only with explicit consent of the client. Data are managed accoring to the Regulation (EU) 2016/679 of the European Parliament and of the Councilof 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation) (OJ L 119, 4.5.2016). Yes, I agree. Is this an important enough priority that you can allocate or find the financial resources towards a solution? Yes No
