SLU Parkinson's Study – Screening Questionnaire

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1975)

City and State

Consent for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Are you between the ages of 30 and 85?

Yes No

Have you been diagnosed with Parkinson's disease by a neurologist or movement disorder specialist?

Yes No

Are you able to walk 30 feet without assistance?

Yes No

Have you ever been diagnosed with REM sleep behavior disorder (RBD)?

Yes No

Do you have any history of significant cognitive impairment (e.g., dementia)?

Yes No Unsure

Do you speak and understand English fluently?

Yes No

Are you willing to wear a small sensor on your waist for 1 week to measure physical activity?

Yes No

Would you be open to returning annually for follow-up visits (2.5–3 hours per year)?

Yes No Maybe

Are you interested in participating in an optional balance testing visit (separate session, ~60 minutes)?

Yes No Maybe

How would you prefer to be contacted?

Email Call Text No Preference

Please select all that apply