Tremor Assessment Survey
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Name
*
First
Last
Date / Time
Date
Time
Country of residence
Language (please include all)
Email
*
Which is your dominant hand for most/all of your activities?
Right
Left
Unsure
Which hand do you use for writing?
Right
Left
Unsure
Which hand has the tremor?
Right
Left
Both
Which hand has the worst tremor?
Right
Left
Unsure
Is your speech:
Normal
Mild voice tremulousness when nervous only.
Mild voice tremor, constant.
Moderate voice tremor.
Severe voice tremor. Some words difficult to understand.
Feeding (other than liquids):
Normal
Mildly abnormal. Can bring all solids to mouth, spilling only rarely.
Moderately abnormal. Frequent spills of peas and similar foods. May bring head at least halfway to meet food.
Markedly abnormal. Unable to cut or uses two hands to feed.
Severely abnormal. Needs help to feed.
Bringing liquids to mouth (drinking):
Normal
Mildly abnormal. Can still use a spoon, but not if it is completely full.
Moderately abnormal. Unable to use a spoon. Uses cup or glass.
Markedly abnormal. Can drink from cup or glass, but needs two hands.
Severely abnormal. Must use a straw.
Hygiene: (examples- washing, shaving, brushing teeth, putting on make-up, mascara and lipstick)
Normal
Mildly abnormal. Able to do everything, but is more careful than the average person.
Moderately abnormal. Able to do everything, but with errors; uses electric razor because of tremor.
Markedly abnormal. Unable to do most fine tasks, such as putting on lipstick or shaving (even with electric shaver), unless using both hands.
Severely abnormal. Unable to do any fine-movement tasks.
Dressing:
Normal
Mildly abnormal. Able to do everything, but is more careful than the average person
Moderately abnormal. Able to do everything, but with errors.
Markedly abnormal. Needs some assistance with buttoning or other activities, such as tying shoelaces.
Severely abnormal. Requires assistance even for gross motor activities.
Writing:
Normal
Mildly abnormal. Legible. Continues to write letters.
Moderately abnormal. Legible, but no longer writes letters.
Markedly abnormal. Illegible.
Severely abnormal. Unable to sign checks or other documents requiring signature.
Working:
Tremor does not interfere with the job.
Able to work, but needs to be more careful than the average person.
Able to do everything, but with errors. Poorer than usual performance because of tremor.
Unable to do regular job. May have changed to a different job because of tremor. Tremor limits housework, such as ironing.
Unable to do any outside job; housework very limited.
What is your occupation?
Social activities:
No changes
Minimal change in social activities, still socializes.
Moderate change in social activities, avoids encounters with strangers.
Marked change in social activities, avoids encounters with friends.
Severe change in social activities, avoid any public encounters.
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