Date of Initial Diagnosis *
Other Diagnoses & Dates How would you describe your current medical condition?* Do you have or have you suffered from the followings: * Allergies, Vaccination, drugs, hay fever Heart Problem High Blood Pressure Asthma Lung Disease Epilepsy Psychiatric problems - nervousness, depression Gastrointestinal problems Liver Problems Hepatitis A Hepatitis B Hepatitis C Renal Problems Kidney Problems Musculoskeletal Problems Osteoporosis Osteoarthritis Blood Disorder Thrombosis Diabetes Type1 Diabetes Type2 Thyroid Disorde Menopause HIV/AIDS Cancer Surgery None of the above
If YES to any choices above, please elaborate: Are you Currently Taking Any of the Following Medications: * Chemotherapy Anticoagulants Antibiotics Steroids None of the above
Do you have any of the following Sensory/Motor/Smell/Vision Loss symptoms? Upper limbs Upper limb Lower limbs Lower limbs Thorax Thorax Pelvis Pelvis Face below eyes Face below eyes Face above eyes Face above eyes Eye Movement Affected Eye Movement Affected Loss of Sense of Smell Left Eye Visual Field Loss Left Eye Visual Field Loss Right Eye Visual Field Loss Right Eye Visual Field Loss Mild Dementia Moderate Dementia Severe Dementia Seizures None of the above
Do you have any of the following symptoms? * Difficulty putting words in correct order or context Difficulty articulating words Difficulty finding the correct word Inability to speak Inability to identify common objects Additional speech difficulties Mild difficulty swallowing Moderate difficulty swallowing Severe difficulty swallowing Mild difficulty gait impairment Moderate difficulty gait impairment Severe difficulty gait impairment Bowel incontinence Bladder incontinence None of the above
Please list all medications you are currently taking, date started, date stopped, dose, and strength.* List all Nutritional Supplements You are Taking. Please Include Brand Names and Dosages* Please choose one of the followings which best describes your moving ability.* Asymptomatic, fully active Walks normally, but reposts fatique that interferes with athletic or other demanding activities Abnormally gait or episodic imbalances; gait disorder is noticed by family and friends; able to walk 25 feet (8 meters) in 10 seconds or less Walks independently; able to walk 25 feet in 20 seconds or less Requires unilateral support (cane or single crutch) to walk; walks 25 feet in 20 seconds or less Requires bilateral support (canes, crutches, or walker) and walks 25 feet in 25 seconds or less; OR requires unilateral support but needs more than 20 seconds to walk 25 feet Requires bilateral support and more than 20 seconds to walk 25 feet; may use wheelchair on occassion Walking limited to several steps with bilateral support; unable to walk 25 feet; may use wheelchair for most activities Restricted to wheelchair; able to transfer self independently Restricted to wheelchair; unable to transfer self independently
