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Neurology Center of Fairfax is implementing Patient Connect by Luma as a way for you to complete your forms online before coming to the office.
You will receive a text from (703) 574-0867 with your appointment confirmation, reminders, and forms link.
Please call our office with any questions.

forms-header

Parkinson’s Form

Parkinson’s Form

LinkedIn

This field is for validation purposes and should be left unchanged.

Patient first name(Required)

Last name(Required)

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Date(Required)

MM slash DD slash YYYY

1- Medication Name

Strength

Time & Dose (# of tablets)

Side effects

2- Medication Name

Strength

Time & Dose (# of tablets)

Side effects

3- Medication Name

Strength

Time & Dose (# of tablets)

Side effects

Compulsive behaviors?

Yes

No

Compulsive behavior details

History of glaucoma?

Yes

No

Glaucoma details

History of melanoma?

Yes

No

Melanoma details

Motor symptoms in last 6 months

Tremor?

Yes

None

Rigidity?

Yes

None

Slowness?

Yes

None

Dyskinesia/Involuntary Movement?

Yes

None

Abnormal hand/foot/trunkal posturing?

Yes

None

Walking symptoms in last 6 months

Shuffling?

Yes

None

Start hesitation?

Yes

None

Freezing?

Yes

None

Imbalance?

Yes

None

Assistive devices?

Yes

No

Type of device(s)

Falls?

Yes

No

Fall details

Activities of daily living/dressing & showering

Needs help with activities of daily living?

Yes

No

Daily living assistance details

Difficulty with swallowing, eating, or drinking?

Yes

No

Sustenance details

Associated symptoms

Constipation/diarrhea?

Yes

No

Bowel issue details

Urinary?

Yes

No

Urinary issue details

Sexual dysfunction?

Yes

No

Sexual issue details

Orthostasis?

Yes

No

Orthostasis details

Double vision?

Yes

No

Double vision details

Depression?

Yes

No

Depression details

Anxiety?

Yes

No

Anxiety details

Sleep disturbance?

Yes

No

Sleep disturbance details

Hallucinations?

Yes

No

Hallucinations details

Confusion?

Yes

No

Confusion details

Memory loss?

Yes

No

Memory loss details

Speech difficulty?

Yes

No

Speech difficulty details

Slowness processing information?

Yes

No

Information processing details

Other symptoms?

Yes

No

Other symptom details

Rev 6.16.2022

Locations

Fairfax Office
3020 Hamaker Ct, Suite 400
Fairfax, VA 22031
703-876-0800 | Fax: 703-876-0866

Reston Office
1830 Town Center Drive, Suite 305
Reston, VA 20190
703-876-0800 | Fax: 703-876-0866

Sleep Diagnostic and Treatment Center
3020 Hamaker Ct, Suite 400
Fairfax, VA 22031
703-876-2850 | Fax: 571-308-1158

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