Hello everyone!
This is a basic form that can be used by anyone who is contacting Dr. Costantini to start on his HDT protocol. The idea of this form is that it should give him enough information so that he does not have to send extra emails back and forth to ask more questions of you. I tried to keep the form as simple as possible so that it can be filled out quickly and easily. All you need to do is copy it from below using your mouse and then paste it into your email to Dr. Costantini. Once it is pasted into your email, simply answer the questions and send your email to : carapetata@libero.it
That's it and then Dr. Costantini will respond as soon as possible. I will be adding a link to this page on the "thiamine primer page", so the two easy ways to find this form is to go to the thiamine primer page and click on the proper link or click on my icon ( the chipmunk in the circle). A third way would be to search for " Contact Form" in the search box in the upper right hand corner of the page.
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PRELIMINARY PATIENT INFORMATION
Date :
0. Are you a member of the HealthUnlocked Parkinson's Movement forum?
1. NAME :
2. AGE :
3. WEIGHT :
4. HEIGHT :
4. APPROXIMATE DATE OF DIAGNOSIS WITH PD? :
5. APPROXIMATE DATE OF FIRST SYMPTOMS OF PD? :
6. CURRENT LIST OF ALL MEDICATIONS AND DOSAGE YOU ARE TAKING? :
7. CURRENT LIST OF ALL VITAMINS, SUPPLEMENTS AND ALTERNATIVE TREATMENTS YOU ARE TAKING AND DOSAGES? :
8. CURRENT LIST OF ALL OF YOUR HEALTH ISSUES OR DISEASES?
9. WHAT IS THE CURRENT LENGTH OF YOUR "ON TIMES" AND "OFF TIMES"?
10. CURRENT LIST OF ALL SUBSTANCES THAT YOU ARE ALLERGIC TO?
11. ARE YOUR PD SYMPTOMS WELL CONTROLLED AT THIS TIME?
12. DO YOU CURRENTLY USE A CANE, WALKER OR WHEEL CHAIR ?
13. PLEASE WRITE ANY OTHER INFORMATION THAT YOU FEEL IS RELEVANT TO YOUR CURRENT HEALTH SITUATION HERE :
14. PLACE A PLUS SIGN (+) AFTER EACH ITEM BELOW THAT APPLIES TO YOU.
1. tremor
2. constipation or other digestion issues
3. brain fog
4. insomnia or difficulty falling asleep or staying asleep
5. inability to smell or taste
6. instability when walking
7. dizziness or lightheadedness
8. pain in joints
9. pain in muscles
10. inability to write, use a keyboard or mouse
11. slow movement
12. can't walk
13. muscle cramps
14. dyskinesia
15. freezing
16. anxiety
17. dementia of any type
18. bradykinesia
19. dystonia
20. shuffling
21. depression
22. apathy
23. inability to get up from a seated position without assistance
24. visual problems
25. hallucinations
26. despair
27. dry eyes
28. inability to use either hand or arm effectively
29. inability to focus or concentrate for any length of time
30. foot or leg drag
31. stooped posture
32. problems with swallowing or drinking
33. bladder issues
35. unable to move around in bed without great effort
36. tremor that you feel internally
37. lost facial expression or inability to smile
38. always grabbing on to stationary objects in order to maintain balance
39. forgetfulness
40. drooling / sialorrhea
41. Male
42. Female