Parkinson’s Patient Application

Personal Information

Name

Phone

Date Of Birth

Weight:

Height:

Email

1. Have you tried ibogaine or other psychedelic medicines?

2. Do you have any dietary restrictions or preferences?

3. Do you have any allergies (medications, foods, animals)?

4 Please explain how you came to know about New Path:
Alumni referralInternet searchTherapist/Consultant referralFacebookInstagramYouTube

Medical Information

1. Parkinson's Disease Stage: Please circle the stage of Parkinson's disease (e.g., Hoehn and Yahr scale: 1-5):

1 MILD2 MILD3 MODERATE4 SEVERE5 SEVERE
2. Medications: List current medications, dosages, and frequencies

3. Medical History: Document relevant medical conditions (e.g., diabetes, hypertension):

4. Surgical History: Record any surgeries or interventions related to Parkinson's disease:


Physical Capacity

5. Mobility (Check one box)
1. Ability to walk independently2. Requires assistance with walking/uses walker3. Unable to walk

6. Stair Navigation (Check one box)
1. Can climb stairs independently2. Requires assistance with climbing stairs3. Unable to climb stairs

7. Balance and Coordination (Check one box):
1. Good balance and coordination2. Some balance and coordination impairment3. Significant balance and coordination problems

8. Activities of Daily Living [ADLs] (Check one box):
a. Bathing and showering
Fully independentNeeds partial assistanceRequires complete assistance

b. Dressing and grooming
Fully independentNeeds partial assistanceRequires complete assistance

c. Toileting
Fully independentNeeds partial assistanceRequires complete assistance

d. Eating/Feeding
Fully independentNeeds partial assistance (aside from cutting meat)Requires feeding


Psychological and Cognitive

9. Cognitive Function: Assess cognitive impairment (e.g., Mini-Mental State Examination)
10. Mood and Emotional Well-being (Please check all that apply):
DepressionAnxietyApathyPost-Traumatic StressObsessive-Compulsive DisorderMood or Personality Disorder

11. Sleep Quality: Evaluate sleep disturbances and insomnia
Sound sleep without frequent disturbancesSome restlessness and disturbances (dreams, bladder, etc.)Frequent disturbances and restlessnessInsomnia (inability to sleep, inability to maintain sleep/achieve REM)

12. Social Support: (availability of support from family, friends, and caregivers)
Support system is strong, long-termSupport system in place, but could use some enhancementsSupport system is weak, needing education/respite/relief

Caregiver and Support Information

13 Primary Caregiver: Name and contact information (phone, email address):

14. Support Services: List any additional support services (e.g., home care, physical therapy):

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