Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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

Cognitive symptoms *

Please indicate what symptoms have you been experiencing:

Focus and concentration difficulties

Memory impairments

Hallucinations

Decision making difficulty

Learning problems

Mood symptoms *

Please indicate what symptoms have you been experiencing:

Depression

Anxiety

Apathy

Lack of motivation

Isolation

Addictive behaviours

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.

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

Preferred Time for Activities and Consultations:

Morning

Afternoon

Evening

Are you comfortable with using technology (apps, online forms) for tracking your progress?

Yes

No

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