Access to Care for Parkinson's Disease
Section A -- Parkinson's Disease Services
A range of health services potentially needed for Parkinson's Care are listed. For each of the types of health services indicate your need for and use of the service and for those used, the source of payment for the service. 

Mark the circle (point and click your mouse) to best describe your (or the Parkinson's patient) NEED for the service: 
*  the service was NOT NEEDED IN THE PAST YEAR, 
*  the service was NEEDED by you but NOT ACCESSIBLE in the past year because of lack of coverage, lack of information, cost or other barriers. 
* the service was NEEDED and USED in the past year.

If the service was USED IN THE PAST YEAR, indicate all significant sources of payment:
* Health Insurance coverage including Medicare, Medicaid, and VA health benefits.. 
* Social Programs including government assistance and private charities.. 
* Family or self pay.
1. Treatment for PD by Primary Care Physician
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
2. Treatment for PD by a General Neurologist
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
3. Treatment for PD by a Movement Disorder  Specialist
    (A neurologist who primarily treats Parkinson's Disease)
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
4. Surgical treatment for PD (e.g. pallidotomy, deep brain stimulation)
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
5. Treatment for PD by other Specialist (e.g. psychiatry, eye or digestion)
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
6. Treatment for PD with Prescription Drugs
Medications that require physician supervision. Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
7. Health or social services coordinator or case manager for PD
Help with planning and coordination of a range of PD services by a case manager such as a social worker or nurse. ..... Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
8. Counseling services for PD
Includes advice on nutrition, alternative therapy or personal and occupational issues (medical services, financial, legal).... Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
9. Rehabilitative services (Physical Therapy, Occupational Therapy, Speech Therapy)
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
10. Adult Day Care / Senior Citizen Center or Recreation/Exercise Program
Two or more days per week Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
11. Home Health (Skilled nursing care) or Home Help (Personal care assistance, home health assistance, home delivered meals)
Answer need and if response is USED, answer source)
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
12. Assisted Living Facility, Congregate Housing, or Group Home (Long term residence with assistance)
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
13. Nursing Home, Long Term Residential Care
Answer need and if response is USED, answer source
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
14. Acute Care - Hospital Stay, Emergency Room Care, or Extended Care (Skilled Nursing Facility)
Answer need and if response is USED, answer source)
Service need in past year
Not needed
Not accessible
Used
Major sources of payment for services in past year
Health Insurance
Social Program
Family
Section B -- Parkinson's Patient Description
Please describe the Parkinson's patient (yourself) by answering the following questions.
Today's Date
MM/DD/YYYY
Current Age (years)
Age at diagnosis with PD
Gender
Male
Female
Not Answered
Education
8th Grade or less
Some high school
High school graduate or GED
Some college or 2 year degree
4 year college graduate
More than 4 year college degree
Not Answered
Ethnicity
Non-Hispanic White
Hispanic or Latino
Black or African American
Asian or Pacific Islander
Native American or Alaskan Native
Not Answered
Employment
Indicate the extent of the patient's employment,... and if NOT fully employed, select primary reason..
Employment Status
Employed Full Time
Employed Part Time
Not Employed
Not Answered
Less than Full Time Employment due to:
Retirement
Disability
Student
Other
Not Answered
Income
Please indicate the income category of the PD patient including all household income.
Annual Household Income
under $20,000
$20,000 to $60,000
$60,000 to $100,000
above $100,000
Not Answered
Primary Sources of Income (check all significant sources that apply)
Employment
Savings and Investments
Disability Payments
Social Security
Private Pension
Public Assistance
Health Insurance
Coverage for medical expenses of PD patient.
Payer Primary health insurance coverage provided by:
No insurance
Employer group
Self pay individual
Medicare only
Medicare and supplemental coverage
Medicaid
Federal (Military, VA, CHAMPUS)
Not Answered
Type DEFINITIONS: Unrestricted -- fee for service to any qualified provider. / Preferred Provider - discounted fees to service providers on the health plan's panel. / HMO - covered services restricted to providers on health plan's panel unless a referral is approved.
Unrestricted 
Preferred Provider
HMO
Not Answered
Section C -- Respondent Identification
Please provide your identification information so we can be in contact with you to solicit your views and share information on Quality and Access to Parkinson's Care. This information is for internal use only and will not be distributed without your permission. Any findings published from this survey will display summary statistics only and will NOT identify individual respondents.
Your relation to the Parkinson's patient
Patient
Spouse of patient
Child of patient
Other caregiver
Paid healthcare provider
Not Answered
If you are NOT the Patient, Name of PD Patient
Respondent Name
Please identify the primary contact person for the PD patient described in this survey.
First Name
Last Name
Mail Address
Please provide respondent's mailing address.
Street number and name
Company name or detail on building/floor/suite
City or town
State or Province
Postal code or zipcode
Telephone Numbers
Please provide respondent's contact numbers where available
Home telephone number
Work telephone number
Fax number
Cell phone number
Internet
Please provide internet contact information for respondent where available
EMail address
Instant Message Provider
ICQ
AOL- Instant Message
Other
None
Instant Message number or name
Web site or other internet presence
Preference about use of your contact information
Please tell us your preferences about the types of communication you would like to receive from us on issues of promoting Quality and Access to Parkinson's Care. ..... Note again that all your data will be kept confidential, and only reported publicly as part of summary statistics.
EMail List Put me on your email list for periodic updates on public health policy for PD. Yes
Advocacy mail list Put me on your Advocacy mailing list to receive updates on promoting better access to PD services. Yes
Contributor mail list Contact me to make a financial contribution to support research on quality and access to PD services. Yes
General mail list Put me on your General mailing list to receive information on access to and quality of PD services. Yes
No contact I do not wish to be contacted. Yes