PD Patient Profile for Assistance Tools Question Title * 1. Grooming Tasks: Rate your quality of life for the following tasks 1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = moderate severe difficulty 5 = most difficult Brushing teeth (electric toothbrush) Brushing teeth (electric toothbrush) 1 = no difficulty Brushing teeth (electric toothbrush) 2 = mild difficulty Brushing teeth (electric toothbrush) 3 = moderate difficulty Brushing teeth (electric toothbrush) 4 = moderate severe difficulty Brushing teeth (electric toothbrush) 5 = most difficult Brushing teeth (manual toothbrush) Brushing teeth (manual toothbrush) 1 = no difficulty Brushing teeth (manual toothbrush) 2 = mild difficulty Brushing teeth (manual toothbrush) 3 = moderate difficulty Brushing teeth (manual toothbrush) 4 = moderate severe difficulty Brushing teeth (manual toothbrush) 5 = most difficult Shaving (electric) Shaving (electric) 1 = no difficulty Shaving (electric) 2 = mild difficulty Shaving (electric) 3 = moderate difficulty Shaving (electric) 4 = moderate severe difficulty Shaving (electric) 5 = most difficult Shaving (manual rasor) Shaving (manual rasor) 1 = no difficulty Shaving (manual rasor) 2 = mild difficulty Shaving (manual rasor) 3 = moderate difficulty Shaving (manual rasor) 4 = moderate severe difficulty Shaving (manual rasor) 5 = most difficult Washing Washing 1 = no difficulty Washing 2 = mild difficulty Washing 3 = moderate difficulty Washing 4 = moderate severe difficulty Washing 5 = most difficult Placement of in-ear hearing aids Placement of in-ear hearing aids 1 = no difficulty Placement of in-ear hearing aids 2 = mild difficulty Placement of in-ear hearing aids 3 = moderate difficulty Placement of in-ear hearing aids 4 = moderate severe difficulty Placement of in-ear hearing aids 5 = most difficult coming hair coming hair 1 = no difficulty coming hair 2 = mild difficulty coming hair 3 = moderate difficulty coming hair 4 = moderate severe difficulty coming hair 5 = most difficult Question Title * 2. Dressing Tasks: Rate your quality of life for the following tasks 1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = moderate severe difficulty 5 = most difficult underwear (cloth) underwear (cloth) 1 = no difficulty underwear (cloth) 2 = mild difficulty underwear (cloth) 3 = moderate difficulty underwear (cloth) 4 = moderate severe difficulty underwear (cloth) 5 = most difficult underwear (disposable) underwear (disposable) 1 = no difficulty underwear (disposable) 2 = mild difficulty underwear (disposable) 3 = moderate difficulty underwear (disposable) 4 = moderate severe difficulty underwear (disposable) 5 = most difficult bra bra 1 = no difficulty bra 2 = mild difficulty bra 3 = moderate difficulty bra 4 = moderate severe difficulty bra 5 = most difficult trousers trousers 1 = no difficulty trousers 2 = mild difficulty trousers 3 = moderate difficulty trousers 4 = moderate severe difficulty trousers 5 = most difficult t-shirts t-shirts 1 = no difficulty t-shirts 2 = mild difficulty t-shirts 3 = moderate difficulty t-shirts 4 = moderate severe difficulty t-shirts 5 = most difficult button shirt button shirt 1 = no difficulty button shirt 2 = mild difficulty button shirt 3 = moderate difficulty button shirt 4 = moderate severe difficulty button shirt 5 = most difficult arm placement in button up shirt arm placement in button up shirt 1 = no difficulty arm placement in button up shirt 2 = mild difficulty arm placement in button up shirt 3 = moderate difficulty arm placement in button up shirt 4 = moderate severe difficulty arm placement in button up shirt 5 = most difficult button cuff button cuff 1 = no difficulty button cuff 2 = mild difficulty button cuff 3 = moderate difficulty button cuff 4 = moderate severe difficulty button cuff 5 = most difficult pullover shirt pullover shirt 1 = no difficulty pullover shirt 2 = mild difficulty pullover shirt 3 = moderate difficulty pullover shirt 4 = moderate severe difficulty pullover shirt 5 = most difficult arm placement in pullover shirt arm placement in pullover shirt 1 = no difficulty arm placement in pullover shirt 2 = mild difficulty arm placement in pullover shirt 3 = moderate difficulty arm placement in pullover shirt 4 = moderate severe difficulty arm placement in pullover shirt 5 = most difficult belt placement belt placement 1 = no difficulty belt placement 2 = mild difficulty belt placement 3 = moderate difficulty belt placement 4 = moderate severe difficulty belt placement 5 = most difficult shoes (lace up) shoes (lace up) 1 = no difficulty shoes (lace up) 2 = mild difficulty shoes (lace up) 3 = moderate difficulty shoes (lace up) 4 = moderate severe difficulty shoes (lace up) 5 = most difficult shoes (slip on) shoes (slip on) 1 = no difficulty shoes (slip on) 2 = mild difficulty shoes (slip on) 3 = moderate difficulty shoes (slip on) 4 = moderate severe difficulty shoes (slip on) 5 = most difficult outer jacket outer jacket 1 = no difficulty outer jacket 2 = mild difficulty outer jacket 3 = moderate difficulty outer jacket 4 = moderate severe difficulty outer jacket 5 = most difficult socks socks 1 = no difficulty socks 2 = mild difficulty socks 3 = moderate difficulty socks 4 = moderate severe difficulty socks 5 = most difficult skirt skirt 1 = no difficulty skirt 2 = mild difficulty skirt 3 = moderate difficulty skirt 4 = moderate severe difficulty skirt 5 = most difficult Question Title * 3. BathroomTasks: Rate your quality of life for the following tasks 1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = moderate severe difficulty 5 = most difficult urination urination 1 = no difficulty urination 2 = mild difficulty urination 3 = moderate difficulty urination 4 = moderate severe difficulty urination 5 = most difficult bowel movement (normal) bowel movement (normal) 1 = no difficulty bowel movement (normal) 2 = mild difficulty bowel movement (normal) 3 = moderate difficulty bowel movement (normal) 4 = moderate severe difficulty bowel movement (normal) 5 = most difficult bowel movement (constipated) bowel movement (constipated) 1 = no difficulty bowel movement (constipated) 2 = mild difficulty bowel movement (constipated) 3 = moderate difficulty bowel movement (constipated) 4 = moderate severe difficulty bowel movement (constipated) 5 = most difficult hygiene (general) hygiene (general) 1 = no difficulty hygiene (general) 2 = mild difficulty hygiene (general) 3 = moderate difficulty hygiene (general) 4 = moderate severe difficulty hygiene (general) 5 = most difficult Question Title * 4. Eating Tasks: Rate your quality of life for the following tasks 1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = moderate severe difficulty 5 = most difficult cutting food cutting food 1 = no difficulty cutting food 2 = mild difficulty cutting food 3 = moderate difficulty cutting food 4 = moderate severe difficulty cutting food 5 = most difficult use of fork use of fork 1 = no difficulty use of fork 2 = mild difficulty use of fork 3 = moderate difficulty use of fork 4 = moderate severe difficulty use of fork 5 = most difficult use of spoon use of spoon 1 = no difficulty use of spoon 2 = mild difficulty use of spoon 3 = moderate difficulty use of spoon 4 = moderate severe difficulty use of spoon 5 = most difficult use of knife use of knife 1 = no difficulty use of knife 2 = mild difficulty use of knife 3 = moderate difficulty use of knife 4 = moderate severe difficulty use of knife 5 = most difficult use of standard utensils use of standard utensils 1 = no difficulty use of standard utensils 2 = mild difficulty use of standard utensils 3 = moderate difficulty use of standard utensils 4 = moderate severe difficulty use of standard utensils 5 = most difficult use of over-sized utensils use of over-sized utensils 1 = no difficulty use of over-sized utensils 2 = mild difficulty use of over-sized utensils 3 = moderate difficulty use of over-sized utensils 4 = moderate severe difficulty use of over-sized utensils 5 = most difficult Question Title * 5. Writing Tasks: Rate your quality of life for the following tasks 1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = moderate severe difficulty 5 = most difficult handwriting handwriting 1 = no difficulty handwriting 2 = mild difficulty handwriting 3 = moderate difficulty handwriting 4 = moderate severe difficulty handwriting 5 = most difficult using standard pen using standard pen 1 = no difficulty using standard pen 2 = mild difficulty using standard pen 3 = moderate difficulty using standard pen 4 = moderate severe difficulty using standard pen 5 = most difficult using over-sized pen using over-sized pen 1 = no difficulty using over-sized pen 2 = mild difficulty using over-sized pen 3 = moderate difficulty using over-sized pen 4 = moderate severe difficulty using over-sized pen 5 = most difficult using computer using computer 1 = no difficulty using computer 2 = mild difficulty using computer 3 = moderate difficulty using computer 4 = moderate severe difficulty using computer 5 = most difficult using i-pad using i-pad 1 = no difficulty using i-pad 2 = mild difficulty using i-pad 3 = moderate difficulty using i-pad 4 = moderate severe difficulty using i-pad 5 = most difficult using cell phone using cell phone 1 = no difficulty using cell phone 2 = mild difficulty using cell phone 3 = moderate difficulty using cell phone 4 = moderate severe difficulty using cell phone 5 = most difficult Question Title * 6. Gastrointestinal tasks: Rate your quality of life for the following tasks 1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = moderate severe difficulty 5 = most difficult cough cough 1 = no difficulty cough 2 = mild difficulty cough 3 = moderate difficulty cough 4 = moderate severe difficulty cough 5 = most difficult food debris food debris 1 = no difficulty food debris 2 = mild difficulty food debris 3 = moderate difficulty food debris 4 = moderate severe difficulty food debris 5 = most difficult swallowing swallowing 1 = no difficulty swallowing 2 = mild difficulty swallowing 3 = moderate difficulty swallowing 4 = moderate severe difficulty swallowing 5 = most difficult speech speech 1 = no difficulty speech 2 = mild difficulty speech 3 = moderate difficulty speech 4 = moderate severe difficulty speech 5 = most difficult Question Title * 7. Use of Aids-Please answer by checking the appropriate lines.Yes - I currently useNo - I do not use Yes No over-sized toothbrush over-sized toothbrush Yes over-sized toothbrush No electric razor electric razor Yes electric razor No standard razor standard razor Yes standard razor No over-sized razor over-sized razor Yes over-sized razor No standard pen standard pen Yes standard pen No over-sized pen over-sized pen Yes over-sized pen No zipper aid zipper aid Yes zipper aid No long shoe horn long shoe horn Yes long shoe horn No bottle opener bottle opener Yes bottle opener No button hook button hook Yes button hook No shoe/sock aid shoe/sock aid Yes shoe/sock aid No cane cane Yes cane No walker walker Yes walker No walking sticks walking sticks Yes walking sticks No wheel chair wheel chair Yes wheel chair No bathroom grab bars bathroom grab bars Yes bathroom grab bars No shower bench shower bench Yes shower bench No door knob gripper door knob gripper Yes door knob gripper No door knob extension door knob extension Yes door knob extension No nail clipper over-sized nail clipper over-sized Yes nail clipper over-sized No dressing aid stick dressing aid stick Yes dressing aid stick No reacher grab tool reacher grab tool Yes reacher grab tool No easy key holder easy key holder Yes easy key holder No zipper lubricant zipper lubricant Yes zipper lubricant No Question Title * 8. Please select whether you think the following aids are helpful (yes/no) Yes No over-sized toothbrush over-sized toothbrush Yes over-sized toothbrush No electric razor electric razor Yes electric razor No standard razor standard razor Yes standard razor No over-sized razor over-sized razor Yes over-sized razor No standard pen standard pen Yes standard pen No over-sized pen over-sized pen Yes over-sized pen No zipper aid zipper aid Yes zipper aid No long shoe horn long shoe horn Yes long shoe horn No bottle opener bottle opener Yes bottle opener No button hook button hook Yes button hook No shoe/sock aid shoe/sock aid Yes shoe/sock aid No cane cane Yes cane No walker walker Yes walker No walking sticks walking sticks Yes walking sticks No wheel chair wheel chair Yes wheel chair No bathroom grab bars bathroom grab bars Yes bathroom grab bars No shower bench shower bench Yes shower bench No door knob gripper door knob gripper Yes door knob gripper No door knob extension door knob extension Yes door knob extension No nail clipper over-sized nail clipper over-sized Yes nail clipper over-sized No dressing aid stick dressing aid stick Yes dressing aid stick No reacher grab tool reacher grab tool Yes reacher grab tool No easy key holder easy key holder Yes easy key holder No zipper lubricant zipper lubricant Yes zipper lubricant No Done