Please Complete The form below. Please Answer all questions.

Informed Consent Form

You have been invited to participate in a research study entitled “Non-Motor Symptons on Parkinson's Disease” Participation in this study would involve completing an information sheet and the Parkinson’s Disease Questionnaire-39 (PDQ-39; the most widely used questionnaire to assess health status in PD). The information you provide will benefit patients and carers as well as treatment providers so that they can better help you.

Your participation is completely voluntary, and all of the information that you provide will be strictly confidential. If you choose to participate in this study, please complete your name and provide the data in any designated areas.
First Name *
Middle name/Initial
Last Name *
Address Line 1 *
Address Line 2
City *
State *
Zip *
Country
e-mail address *
Phone *
User Name *
Password (12 characters maximum) *
Re-type your Password *
Date of Birth *
(Please type the specific digits to represent your birthdate using the following format MM/DD/YYYY, such as "03/20/1943"
Gender Male: Female: *
Ethnicity or Race Caucasian: African American:
Hispanic: Asian:
Native American : Other : *
How many years of school did you complete? *
Marital Status Single: Married: Separated:
Divorced: Widowed:
Partnered/Common Law: *
Do you live alone? Yes: No: *
At what age where you diagnosed with Parkinson's disease? *
Please type in specific digits for your response; e.g., "45" rather than "forty five".
I consent to participate in this survey. *