Sleep and Parkinson's Survey

3.

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

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

2.Are you Male or Female?

Male

Female

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

Yes

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

Other (please specify)

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)

Alert, wide awake, feeling vital, peak alertness

Awake, able to concentrate, but not at peak

Awake, but not fully attentive, responsible, but let down a little

A little foggy, a little sleepy, losing interest, still able to function

Foggy, prefer to be lying down, slowed down

Very sleepy, woozy, fighting sleep

Other (please specify)

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

I have sometimes fallen asleep at inappropriate times such as when driving, in conversation or when eating.

I have sometimes been so sleepy that I became confused or lost track of the topic during a conversation

My daytime sleepiness affects my work

I have had accidents or near accidents when driving because I felt so sleepy

Other (please specify)

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

Other (please specify)

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

14.Number of alcoholic drinks and the time consumed

time

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

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

Lunchtime

Early evening (before 9.00 pm)

Late evening (after 9.00 pm)

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

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