Patient Registration

1. Patient Basic Information

FullName

Age

Gender

City

District

State

Country

MobileNumber

WhatsAppNumber

Email

2. Parkinson's Information

Diagnosis Status

Yes

Suspected / Under Evaluation

DiagnosisYear

SymptomsStartedAge

First Symptoms Noticed

Slow movement (Bradykinesia)

Hand / leg tremor

Body stiffness

Walking difficulty

Balance problem

Speech change

Writing changes

Other Symptoms

3. Current Symptoms

Movement Related

Tremor

Slowness of movement

Stiffness

Walking difficulty

Freezing while walking

Balance issues

Falls

Uncontrolled movements (Dyskinesia)

Non-Movement Symptoms

Constipation

Sleep problems

Anxiety / Depression

Memory changes

Fatigue

Pain

Other

4. Current Treatment Details

Taking Parkinson's Medicines?

MedicineNames

DoctorHospital

DBS Surgery

5. Support Requirement

Parkinson’s awareness & education

Guidance to reach specialist doctors

Medicine support

Surgery / DBS support information

Rehabilitation / exercise guidance

Caregiver support

Financial assistance guidance

Government scheme information

6. Economic Information

Need Financial Assistance

Able to Manage Treatment Expenses

Prefer Not To Answer

Consent & Privacy Declaration

I agree and give my consent.

PatientCaregiverName

ConsentDate

National Parkinson's Patient Registration Initiative

Movement Related

Non-Movement Symptoms

Awareness

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Patient Registration

National Parkinson's Patient Registration Initiative

Movement Related

Non-Movement Symptoms

Awareness

Get Involved

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