1. Default Section

* 1. Are you Male or Female?

* 2. How old are you?

* 3. How long have you had Parkinson's?

* 4. How tall are you and what is your weight?

* 5. Over the past 10 years, would you say you drink

* 6. Over the past 10 years would you say you have been a

* 7. Have you ever been told by your doctor that you have any of the following?

  Yes No
Diabetes?
Insulin dependent diabetes?
Asthma?
Irritable Bowel Syndrome?
Coeliac disease?
Rheumatoid Arthritis?
Food allergy?
Food intolerance?
Hayfever or dust allergy?

* 8. Do you regularly take anti-inflammatory medicines, if so which?

* 9. If yes, do you feel it has an affect on your Parkinson's and if so what?

* 10. Which, if any, of the following do you have?

* 11. Do you use laxatives?

* 12. If yes, how often do you take laxatives?

* 13. On average, how often do you have a bowel movement?

* 14. My appetite is

* 15. When I eat

* 16. I feel hungry

* 17. When do you feel hungry?

* 18. Do you feel hungry when

* 19. Compared to when I was younger, my sense of taste is

* 20. Normally I eat

* 21. I feel sick or nauseated when I eat

* 22. Would you say your diet has an emphasis towards carbohydrates or fatty/oily foods e.g Salmon, Tuna?

* 23. Do you take any vitamins or health food supplements regularly such as amino acids, multivitamins, co enzyme Q10, fish oils, if so which and how?

* 24. Do you eat a lot of chocolate?

* 25. Do certain foods impact on your Parkinson's symptoms, if so which and how?

* 26. Do certain foods effect the efficacy of your Parkinson's medication, if so which and how?

* 27. Have you noticed any patterns or correlation between the state of your Parkinson's and what you eat?

* 28. Have you noticed any patterns or correlation between the state of your Parkinson's and your overall gut function?

* 29. We think people with Parkinson's may have significant insight into cause(s)/progress of their condition. Do you feel that your Parkinson's might be related to a gut issue?

* 30. Do you have any other comments in relation to Parkinson's and the gut?

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