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eCRF compilation for new case
Part 3 - Clinical Features of PD & Investigations
PDQ-39
Total score:
Year of assessment:
2020
2019
2018
NMSQ
Total score:
–
+
Year of assessment:
2020
2019
2018
MMSE
Total score:
–
+
Year of assessment:
2020
2019
2018
SCOPA-AUT
Total score:
–
+
Year of assessment:
2020
2019
2018
Investigations
Brain CT
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Brain MRI
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
DAT scan/ PET
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Transcranial sonography
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Smell testing (e.g., UPSIT, Sniffin Sticks - please specify)
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Polysomnography for RBD
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Myocardial MIBG scintigraphy
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Other (please specify):
Year of most recent study
2020
2019
2018
Result
normal
abnormal
unknown
Treatment of PD
Year of assessment (if possible, please use the same assessment year as when the UPDRS/MDS-UPDRS was administered):
2020
2019
2018
PD medications
Levodopa
no
yes
unknown
COMT inhibitor (entacapone or opicapone)
no
yes
unknown
Dopamine agonist (e.g., pramipexole, ropinirole, piribedil, rotigotine)
no
yes
unknown
MAO-B inhibitor (selegiline, rasagiline)
no
yes
unknown
Anticholinergic (e.g., benzhexol, trihexyphenidyl)
no
yes
unknown
Amantadine
no
yes
unknown
Levodopa-equivalent daily dosage (LEDD): (Please use the LEDD calculator provided)
Device-aided therapies for PD:
Functional neurosurgery
no
yes
unknown
Year of surgery:
2020
2019
2018
Apomorphine infusion
no
yes
unknown
Year commenced:
2020
2019
2018
Levodopa-carbidopa intestinal gel
no
yes
unknown
Year commenced:
2020
2019
2018
Part 4
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