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 4 - Environmental/acquired factors prior to PD motor symptom onset

"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.

Date Part 4 form completed:

1. Diabetes mellitus

no
yes
unknown

2. Gout

no
yes
unknown

3. Helicobacter pylori infection

no
yes
unknown

4. Irritable bowel syndrome

no
yes
unknown

5. Inflammatory bowel disease

no
yes
unknown

6. Appendicectomy

no
yes
unknown

7. Vagotomy

no
yes
unknown

8. Melanoma

no
yes
unknown

9. Chronic hepatitis B infection

no
yes
unknown

10. Chronic hepatitis C infection

no
yes
unknown

11. Chronic renal failure

no
yes
unknown

MERQ-PD-B Environmental Questionnaire

1. Over your lifetime, have you ever had a job in which you used any type of pesticide, including herbicides, fungicides, or fumigants?:

Yes
No
Uncertain

2. Over your lifetime, were you ever exposed to pesticides, including herbicides, insecticides, fungicides or fumigants used on your home, lawn, garden or on a pet?:

Yes
No
Uncertain

3. Over your lifetime, have you ever worked with chemical solvents for more than 6 months?:

Yes
No
Uncertain

4. Over your lifetime, have you ever worked with heavy metals for more than 6 months?:

Yes
No
Uncertain

5. Over your lifetime, have you ever worked with any other chemicals or fumes for more than 6 months?:

Yes
No
Uncertain

Specify:

6. Before you were diagnosed with PD, on average, how many cups of a caffeine containing beverage (e.g. coffee, tea, soda) did you drink each day, during the times you were drinking caffeine-containing beverages?:

6.1. Regular caffeine drinker (at least one cup/day):

Yes
No
Uncertain

7. At present, how many cups of a caffeine containing beverage do you drink on a typical day?:

8. Before you were diagnosed with PD, did you ever smoke cigarettes regularly, that is at least 1 cigarette per day for at least 6 months?:

Yes
No
Uncertain

8.1 For how many years did you smoke cigarettes regularly?:

19.2 During the time that you smoked regularly, about how much did you smoke per day? (Cigarettes/day):

9. Do you smoke cigarettes regularly now?:

Yes
No
Uncertain

9.1 How much do you smoke per day? (Cigarettes/day):

10. Before you were diagnosed with PD, did you live with a smoker?:

Yes
No
Uncertain

11. Before you were diagnosed with PD, did you ever have a head injury where you lost consciousness or were diagnosed with a concussion by a doctor?:

Yes
No
Uncertain

11.1 In what year did the head injury occur?:

12. Before you were diagnosed with PD, did you ever have one or both ovaries surgically removed?:

Yes
No
Uncertain

12.1 In what year did the surgery occur?:

13. Before you were diagnosed with PD, were you ever diagnosed with depression?:

Yes
No
Uncertain

13.1 In what year?:

14. Before you were diagnosed with PD, were you ever diagnosed with anxiety?

Yes
No
Uncertain

14.1 In what year?: