Total Care Program for Parkinson's Disease

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Required format:

iskjz3rJukZo6sgqAMBYVAVXtqwSNao46Z62ibL

Please complete the form below.

To learn more about the program, visit us at:

https://utswmed.org/TotalCare

or write to OBITotalCareProgram@utsouthwestern.edu.

Thank you!

Today's Date

* must provide value

M-D-Y

First Name

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Last Name

* must provide value

Please provide your phone number.

* must provide value

Please provide your email address.

* must provide value

What is your Primary Role?

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Person with Parkinson's Disease

Care Partner

Family/Friend

Medical and/or Ancillary Care Provider

Parkinson's Community Partner

Other

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Would you be interested in sharing your contact information for research purposes at UTSW?

Yes

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Please send an email to request additional information: OBITotalCareProgram@utsouthwestern.edu

Gender

Male

Female

Non-binary

Decline to answer

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Race

American Indian or Alaska Native (AI/AN)

Asian

Black or African American

Native Hawaiian/Pacific Islander (NHPI)

White

Biracial/Multi-racial

Decline to answer

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Ethnicity

Hispanic

Non-Hispanic

Decline to answer

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City of Residence

Zip Code

Are you employed (full-time or part-time)?

Yes

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Would you identify an additional role?

Person with Parkinson's Disease

Care Partner

Family/Friend

Medical and/or Ancillary Care Provider

Parkinson's Community Partner

Other

N/A

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What year were you or your loved one diagnosed with Parkinson's Disease?

What was the age at diagnosis?

You selected Community Partner. Tell us the organization you work for.

Do you or your loved one seek care in Neurology at UTSW Medical Center?

Yes

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How long have you or your loved one been seeking care at UT Southwestern (UTSW) Neurology clinics?

0-2 years

2-5 years

>5 years

N/A

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How may we improve/enhance Parkinson's Disease care and support for you at UTSW?

Expand

Who is managing your Parkinson's disease diagnosis?

Movement Disorder Specialist

General Neurologist

Primary Care Provider

Other

Where else have you sought care in the past or continue to seek care? (this may include fitness and supportive care in the community)

Do you provide care in Neurology at UTSW Medical Center?

Yes

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How would you like to contribute to developing the Total Care Program (TCP)?

Share your experiences and perspective

Participate in an advisory capacity

Attend virtual or in-person Total Care events

Interested in hearing more before I decide

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