DBS Pre-Assessment Patient Form
Please fill in this form as completely as possible. Your answers will help us assess whether Deep Brain Stimulation (DBS) surgery may be appropriate for you. This form can be completed by the patient or a family member. Fields marked * are required.
1
Personal Information
The patient
Spouse
Child / sibling
Other family member
2
Parkinson's Diagnosis
Left side
Right side
Both sides from the start
No — still only one side
Yes — mildly
Yes — significantly
Tremor (shaking)
Slowness of movement
Muscle stiffness
Balance / walking problems
Freezing (feet suddenly stop)
Speech / swallowing
3
Medication & Treatment
Yes
No / never used
Was using, now stopped
Think about the difference between the worst state (before the pill) and the best state (after the pill kicks in)
No change at allVery good improvement
None
Mild
Moderate
Good
Excellent
Drug names and doses if known — leave blank if unsure
Uncontrolled writhing movements, usually 1–2 hours after taking medication
No
Yes — mild
Yes — severe
No
Sometimes
Yes — regularly
4
Memory & Mental Health
None — memory is normal
Mild forgetfulness — still independent
Moderate — needs help daily
Severe memory loss
None
Depression
Anxiety
Hallucinations / delusions
Impulse control problems
5
General Health & Imaging
None
Heart disease
Pacemaker / ICD
Blood thinners
Diabetes
Kidney / liver disease
Active cancer
Yes — normal
Yes — with findings
Not done yet
6
Expectations & Additional Notes
The symptom that most affects daily life
Please fill in all fields, then click Save as PDF. Send the downloaded PDF to us via WhatsApp (+90 531 460 77 38) or email (drmustafasakar@gmail.com). Please also attach any available medical documents (MRI reports, neurology letters, medication lists). We will respond within 48 hours.