Application – Parkinson’s Disease – Throne Biotechnologies

Treatment Application Form

Parkinson's

Please complete the following Clinical form if you wish to be treated for Parkinson’s.

Clinical Form - Parkinson's Disease

Your Name

First Name

Last Name

Your Address

City

State/Province

Zip/Postal

Country

Your Phone

Your email address

Your Birth Date

Your Weight (in pounds)

Your Height in Feet

And Inches

Have You Been Diagnosed With Parkinson's Disease?

Yes, Within The Last Twelve Months

Yes, Between One And Two Years Ago

Yes, More Than Two Years Ago

Not Yet But I Have Some Symptoms Of Parkinson's Disease

If You Have Been Diagnosed With Parkinson's Disease, What Was The Date Of That Diagnosis?

What Stage Of Parkinson's Disease Best Describes You At This Time?

State One, During this initial stage, the person has mild symptoms that generally do not interfere with daily activities. Tremor and other movement symptoms occur on one side of the body only. Changes in posture, walking and facial expressions occur.

Stage Two, Symptoms start getting worse. Tremor, rigidity and other movement symptoms affect both sides of the body or the midline (such as the neck and the trunk). Walking problems and poor posture may be apparent. The person is able to live alone, but daily tasks are more difficult and lengthier.

Stage Three, Considered mid-stage, loss of balance (such as unsteadiness as the person turns or when he/she is pushed from standing) is the hallmark. Falls are more common. Motor symptoms continue to worsen. Functionally the person is somewhat restricted in his/her daily activities now, but is still physically capable of leading an independent life. Disability is mild to moderate at this stage.

Stage Four, At this point, symptoms are fully developed and severely disabling. The person is still able to walk and stand without assistance, but may need to ambulate with a cane/walker for safety. The person needs significant help with activities of daily living and is unable to live alone.

Stage Five, This is the most advanced and debilitating stage. Stiffness in the legs may make it impossible to stand or walk. The person is bedridden or confined to a wheelchair unless aided. Around-the-clock care is required for all activities.

Select The Person Who Performed Your Schwab & England Evaluation From The Dropdown List

Date Of Your Schwab & England Evaluation

The Unified Parkinson's Disease Rating Scale, as modified by the Movement Disorder Society (MDS-UPDRS) is widely used to score the severity of Parkinson's Disease. The Scale has four components, with higher scores indicating greater severity of disease. If you have had such an evaluation, please enter your scores on each component below.

Part I: Nonmotor experiences of daily living: 13 items. Score range: 0–52, 10 and below is mild,22 and above is severe.

Part II: Motor experiences of daily living: 13 items. Score range: 0–52, 12 and below is mild, 30 and above is severe.

Part III: Motor examination: 18 items. Score range: 0–132, 32 and below is mild, 59 and above is severe.

Part IV: Motor complications: 6 items. Score range: 0–24, 4 and below is mild, 13 and above is severe.

Total MDS-UPDRS Score (Parts I-IV)

Date Of Your MDS-UPDRS Evaluation

If You Have Had Your Spinal Fluid Tested For Misfolded Alpha-Synuclein Protein, Enter The Result Here

Date Of The Misfolded Alpha-Synuclein Test

List All Medications That You Take For Parkinson's Disease, Enter "None" If None *

List any other autoimmune conditions that you believe that you have.

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides Your Parkinson's Disease Care

Are You Employed At This Time?

Yes, Full Time (Greater Than 30 Hours Per Week)

Yes, Part Time (Between 20 and 30 Hours Per Week)

Yes, Part Time Less Than 20 Hours Per Week)

Retired

Disabled, Unable To Work

Not Retired But Not Working At This Time

Do You Have Or Need A Caretaker And, If So, Who Supplies That Care?

I can function independently

I live with a family member or friend who provides caretaking services for me

Someone comes to my home to provide caretaking services for four or less hours per day

Someone comes to my home to provide caretaking services for eight or less hours per day

Someone comes to my home to provide caretaking services for twelve or less hours per day

One or more caretakers come to my home to provide caretaking services 24/7

I live in a care facility and that care facility provides my caretaking services

List All Other Chronic Illnesses Or Disorders, Especially If Autoimmune, (enter "None" If none)

List The Reasons For All Hospitalizations Of More Than One Day And The Years In Which They Occurred

List All Major Surgeries And The Years In Which They Occurred

List All Medications That You Take For Any Reason Other Than Parkinson's Disease

List All Allergies To Any Drugs Or Anything Else. Enter "None" If None.

List All Vaccinations For Which You Have Records And Age When Vaccinated

Required HIPPA Privacy Practices Notice: (Follow link below)

Yes, I have reviewed the HIPPA Privacy Practices Notice

HIPPA Privacy Practice Notice

Email Communication Authorization:

Yes, I give permission for Throne Biotechnology and Its doctors to communicate with me regarding my care by Telephone, Text Message, or Email.

If you are human, leave this field blank.

Treatment Application Form Parkinson's

Treatment Application Form

Parkinson's