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1.

Sleep plays such an important part in the management of Parkinson's. Certain factors such as diet and exercise impact the quality of sleep. Parkinson's medication is much more effective after a good night sleep.

The following questionnaire has been designed to help you identify your sleep patterns. Once completed, you can print your completed survey (use the menu on the left hand side) which you can then take to your next appointment with your healthcare professional if you felt it was relevant.

Please note that The Cure Parkinson's Trust and Parkinson's Movement will not share your personal information with any third party, however anonymised results may be published in a written report. By completing the survey you are agreeing to Parkinson's Movement's terms and conditions and data and privacy policy.

With many thanks
The Cure Parkinson's Trust Team

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* 1. How long have you been diagnosed with Parkinson's?

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* 2. Are you Male or Female?

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* 3. Have you ever discussed sleep problems with a healthcare professional (GP, nurse, neurologist, physiotherapist etc)

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* 4. Are you likely to doze or fall asleep in the following situations. (Epworth Sleepiness Scale) Please choose an answer from the drop-down menu.

  Chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour without a break
Sitting talking to someone
Sitting quietly after a lunch without alcohol
After taking medication

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* 5. Some people experience sleepiness in the daytime. Choose one of the following statements to rate your degree of sleepiness during the day (although we do realise this changes on a day to day basis)

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* 6. Please tick any of the statements that apply to you about daytime sleepiness

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* 7. If you experience daytime sleepiness, what time are you most affected?

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* 8. Please choose any of the following which apply to you while asleep. If you have a partner it may be helpful to discuss this.

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* 9. Please mark any of the statements you feel are relevant to you when in bed asleep or awake.

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* 10. On average, what time do you go to bed?

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* 11. On average, what time do you wake in the morning?

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* 12. On average, how many times do you wake in the night

  Average time of waking Average duration of waking
Not at all
Once
Twice
Three times
Four times
More than four times

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* 13. On average number of cups of tea or coffee do you drink a day. (The drop down menus give times that these are drunk)

  time of having coffee or tea time of second coffee/tea time of third coffee/tea time of fourth coffee/tea
1
2
3
4
5
6
more

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* 14. Number of alcoholic drinks and the time consumed

  time time time
0
1
2
3
more

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* 15. I dream (please choose from the drop down menu)

  I remember my dreams
Rarely
About once a week
Several times a week
Nearly every night

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* 16. When I wake up I feel

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* 17. At what time do you eat your main meal?

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* 18. How often do you exercise?

  time of day of exercise time of day of exercise (more than once a week) length of time of exercise
Once a week
Twice a week
Several times a week
Daily
More than once a day

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* 19. What medications do you take in the evening and at what time?

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