eCRF

Data entered into this eCRF are automatically saved

The contributor will also be able to return at a future date to view and/or edit the eCRF should new information regarding the patient/family become available

Part 1 - Demographics & Basic Clinical Details

"Minimal" (mandatory) | "Core" (some items can be missing) | "Extended" (ideal/optional)

Warning: The minimal dataset is not complete yet. Please be reminded that to complete the minimal dataset is mandatory in order to have samples processed for genetic analysis. Please continue or come back when you can complete at least the minimal dataset.

1. Site:

2. Principal Investigator:

3. Local Patient ID:

4. Local Family Code:

5. Relationship (Index or type of relation to Index):

Other Relation:

6. Date of birth:

7. Sex:

Male
Female

8. Ethnicity (check all that apply):

Other, please state:

Asian:

Other, please state:

9. Parental consanguinity ("Are your parents related by blood? For example, could they be cousins?")

no
yes
possibly

Please describe:

10. Country where patient has lived most of his/her life:

11. Education completed:

Primary
Secondary
Tertiary

12. Longest lifetime occupation:

13. Year of PD motor symptom onset ("In what year did you first notice difficulties with your movements?"):

14. Year of PD diagnosis ("In what year were you first told by your doctor that you have Parkinson's?"):

15. Criteria used to diagnose PD (can select more than 1):

2 out of 3 cardinal motor features (bradykinesia, rigidity and resting tremor), and not more likely to be an alternative diagnosis (e.g., Parkinson-plus syndrome, drug-induced parkinsonism, vascular parkinsonism, etc.)
Queen Square Brain Bank Criteria
MDS clinical diagnostic criteria for "Clinically Established PD"
MDS clinical diagnostic criteria for "Clinically Probable PD"