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* 1. How many times in the past 30 days have you:

  Never Occassionally Sometimes Often Always (or cannot do at all)
Had difficulty doing the leisure activities which you would like to do?
Had difficulty looking after your home, e.g. DIY, housework, cooking?
Had difficulty carrying shopping bags?
Had problems walking 100 yards?
Had problems getting around the house as easily as you would like?
Had difficulty getting around in public?
Needed someone else to accompany you when you went out?
Felt frightened or worried about falling over in public?
Been confined to the house more than you would like?
Had difficulty washing yourself?
Had difficulty dressing yourself?
Had problems tying your shoelaces?

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* 2. How many times in the past 30 days have you:

  Never Occassionally Sometimes Often Always
Had problems writing clearly?
Had difficulty cutting up your food?
Had difficulty holding a drink without spilling it?
Felt depressed?
Felt isolated and lonely?
Felt weepy or tearful?
Felt angry or bitter?
Felt anxious?
Felt worried about your future?

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* 3. How many times in the past 30 days have you

  Never Occassionally Sometimes Often Always
Felt you had to conceal your Parkinson's from people?
Avoided situations which involve eating or drinking in public?
Felt embarrassed in public due to having Parkinson's Disease?
Felt worried by other people's reactions to you?
Had problems with your close personal relationships?
Lacked support in the ways you need from your spouse or partner?
Lacked support in the ways you need from your family or close friends?

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* 4. How many times in the past 30 days have you

  Never Occassionally Sometimes Often Always
Unexpectedly fallen asleep during the day?
Had problems with your concentration, e.g. when reading or watching TV?
Felt your memory was bad?
Had distressing dreams or hallucinations?
Had difficulty with your speech?
Felt unable to communicate with people properly?
Felt ignored by people?
Had painful muscle cramps or spasms?
Had aches and pains in your joints or body?
Felt unpleasently hot or cold?

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* 5. Name

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* 6. Age

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* 7. Email Address

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* 8. Please answer the following

  Strongly Disagree Somewhat Disagree Neutral Somewhat Agree Strongly Agree
Exercise has helped to improve the symptoms of my Parkinson's Disease
I would recommend exercise to other individuals with Parkinson's Disease
The progression of my Parkinson's disease has slowed due to my participation in the PD Gladiators Program
I feel a sense of community with the other participants in the PD Gladiators programs and their families

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* 9. How did you first hear about PD Gladiators?

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* 10. How often do you attend PD Gladiators Classes?

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