REQUEST FOR INFORMATION AND ADVICE.

In order to help us to advice you with the appropriate suggestions and to be able to include the patient in our studies, could you please try to answer some or all of the following questions by filling in the boxes in the form below:

The patient has been diagnosed with:

Parkinson's disease
MSA
Shy-Drager Syndrome
Alzheimer
PVS
Other

Period of time since first diagnosis:

Less than one year
More than one year
More than 5 years
More than 10 years

Age:

Less than 50
Over 50
Over 70

PD Medication:

Sinemet
Permax
Selegiline
Comtan
Mirapex
Requip
Stalevo
Tasmar
Other (please specify)

Other type of Medication:

Anti depressants
Barbiturates
Vitamins or Minerals
Other (please specify)

Main Symptoms:

Tremor
Slowness
Rigidity
Other (please specify)

Adverse Reactions:

Dizziness
Dryness of mouth
Constipation
Loss of balance
Speech problems
Sleeping problems
Hallucinations
Swallowing problems
Other: (please specify)

items marked * are required

Name of patient (optional)

Address (optional)

Postcode / zipcode*

Country*

Telephone*

Email*

Nutritional Medicine Research
26 Priestgate, Peterborough
PE1 1WG. United Kingdom

Telephone:
From the USA :
01144 7930 915 588 (8 am to 4 pm)
01144 7919 415 841 (24 hours)

From all other countries:
0044 7930 915 588
0044 7919 415 841 (24 hours)

From the UK:
07930 915 588
07919 415 841 (24 hours)

FAX
From the USA: 01144 7939 010 379
From all other countries: 0044 7939 010 379
From the UK: 07939 010 379