Parkinson's Disease (PD) Survey

We are a branch of a larger market research company, whose goal is to make contact with individuals diagnosed with PARKINSON’S DISEASE (PD) or caregiver of individuals diagnosed. In the coming months, we will reach out to those interested in participating in on-line surveys or telephone discussions to help understand the treatment decision process. When contacted and qualified we will pay respondents for their time (up to $100).

This project is solely concerned with marketing research and there will be no attempts to sell you anything or influence your pharmaceutical or treatment options in any way.

Our clients range from not-for-profit organizations, advertising agencies, advocacy groups and pharmaceutical companies. We work with them as an independent research company to gather the opinions of individuals closest to various disease groups. We have worked in a number of different disease areas including diabetes, autism, Fragile X, hemophilia and many more.

All information collected during the surveys or phone discussions will be completely confidential in that we will not show your name or any other identifying information to our clients.

Question Title

* 1. Are you the patient or caregiver?

Diagnosed Patient

Caregiver

Question Title

* 2. Please identify current disease symptoms.

Tremor

Rigidity

Slowness of movement

Postural instability

Speech Disorder

Cognition

Mood Behavior

Other (please specify)

Question Title

* 3. What medication(s) have/are you utilizing to manage your PARKINSON’S DISEASE? Select those that apply to current and previous management.

	Current	Previous
Levodopa	Levodopa Current	Levodopa Previous
Dopamine Agonists (bromocriptine, pergolide, pramipexole, ropinirole, piribedil, cabergoline, apomorphine and lisuride)	Dopamine Agonists (bromocriptine, pergolide, pramipexole, ropinirole, piribedil, cabergoline, apomorphine and lisuride) Current	Dopamine Agonists (bromocriptine, pergolide, pramipexole, ropinirole, piribedil, cabergoline, apomorphine and lisuride) Previous
MAO-B inhibitors (selegiline and rasagiline)	MAO-B inhibitors (selegiline and rasagiline) Current	MAO-B inhibitors (selegiline and rasagiline) Previous
Clozapine	Clozapine Current	Clozapine Previous
Cholinesterase inhibitors	Cholinesterase inhibitors Current	Cholinesterase inhibitors Previous
Modafinil	Modafinil Current	Modafinil Previous

Other (please specify current or previous)

Question Title

* 4. Please provide information for us to contact you when telephone/internet survey is scheduled. Name, address and phone numbers are optional.

Name:

City/Town:

State:

ZIP: *

Country:

Email Address: *

Phone Number:

Thank you very much for taking the time to fill out this short qualifying questionnaire. We are collecting basic information to match individuals with specific survey requirements in order to invite your valued participation.