Universityoffloridadbsfasttracknetwork

DBS Fast Track Network of Referring Physicians

“Every Parkinson’s Patient Who Needs DBS Should Have DBS”


*Please take 3-5 minutes and fill out this questionnaire and fax it to us at
352-273-5575 c/o Dr. Okun

We will review the consult within 24 hours and schedule the patient for an
appointment in 1-6 weeks (as soon as insurance is verified if the patient
has insurance).


Patient Name: _____________________________________

Patient Home Contact Phone Number(s):

__________________________________________________

Patient Insurance:

___________________________________________________

Referring Physician Name:

___________________________________________________

Referring Physician Address/City:




Referring Physician/Health Care Provider Phone Number:




Referring Physician Fax Number:

________________________________________________________________

Appendix for article: Okun, et. al., Development and Initial Validation of a
Screening Tool for Parkinson’s Disease Surgical Candidates, Neurology, 2004.

DBS Fast Track Network of Referring Physicians

Florida Surgical Questionnaire for Parkinson Disease (FLASQ-PD)
Okun and Foote 2003

Date of Evaluation: _________________________

Please verify a diagnosis of idiopathic PD by assuring your patient meets the UK Brain
Bank Criteria (Hughs, et. al.):

A. Diagnosis of Idiopathic Parkinson’s Disease

Diagnosis 1: Is Bradykinesia present? Yes/No (Please circle response)

Diagnosis 2: (check if present):

___ Rigidity (Stiffness in arms, leg, or neck) ___ Postural instability not caused by primary visual, vestibular, cerebellar, proprioceptive Does your patient have at least 2 of the above? Yes/No (Please circle response) Diagnosis 3: (check if present):

___ Persistent asymmetry affecting side of onset most ___ Excellent response (70-100%) to levodopa ___ Levodopa response for 5 years or more Does your patient have at least 3 of the above? Yes/No (Please circle response) (“Yes” answers to all 3 questions above suggest the diagnosis of idiopathic PD)
B. Findings Suggestive of Parkinsonism Due to a Process Other Than Idiopathic PD

1- RED FLAG – presence of a grasp, snout, root, suck, or Myerson’s sign 1- RED FLAG – supranuclear gaze palsy present 1- RED FLAG – ideomotor apraxia present DBS Fast Track Network of Referring Physicians
1- RED FLAG - presence of new severe orthostatic hypotension not due to medications, erectile dysfunction or other autonomic disturbance within the first year or two of disease 1- RED FLAG – wide based gait present 1- RED FLAG – frequently disoriented or severe cognitive difficulties or severe memory 1- RED FLAG – presence of severe psychosis, refractory to medications 1- RED FLAG- Parkinsonism is clearly not responsive to levodopa, or patient is dopamine naïve, or patient has not had a trial of levodopa (Any of the “FLAG’s” above may be contraindications to surgery) C. Patient Characteristics (Circle the one best answer that characterizes your Parkinson’s
Disease Surgical Candidate): 3 - <61 2. Duration of Parkinson’s symptoms: 3. On-Off fluctuations (medications wear off, fluctuate with dyskinesia and akinesia)? General Patient Characteristics Subscore ____

DBS Fast Track Network of Referring Physicians

D. Favorable/Unfavorable Characteristics
0 – not responsive to levodopa during the best “on” 1 – responsive to levodopa during the best “on” 0 – not responsive to levodopa during the best “on” 1 – responsive to levodopa during the best “on” 0 – on warfarin or another blood thinner besides antiplatelet therapy 1 – not on warfarin or another blood thinner besides antiplatelet therapy 0 - memory difficulties or frontal deficits 1 – no signs or symptoms of cognitive dysfunction 0 – severe depression with vegetative symptoms 1 – occasional hallucinations- probable medication-related Favorable/Unfavorable Characteristics Subscore ____
DBS Fast Track Network of Referring Physicians

E. Medication Trials (circle the best answer)

0 uncertain historical response to levodopa, or no trial of levodopa 1 – history of modest improvement with levodopa 2 – history of marked improvement with levodopa 15. Trial of Sinemet (Carbidopa/Levodopa or Madopar or equivalent): 0 – No Trial or less than three times a day 3 – Sinemet greater than four times a day 0 – No Trial or less than three times a day 1 – Dopamine Agonist three times a day 2 – Dopamine Agonist four times a day 3 – Dopamine Agonist greater than four times a day 1 - Trial of either tolcapone or entacapone 18. Trial of a combination of sinemet or equivalent with a dopamine agonist 1 – Trial of sinemet or equivalent with a dopamine agonist Medication Trial Subscore: _____


FLASQ-PD Scoring:
A. Met Diagnostic Criteria of Idiopathic PD: Yes/No B. Contraindications (FLAGS) Subscore: ____ (8 possible- any flags=likely not a good candidate) C. General Characteristics Subscore ____ (10 possible) D. Favorable/Unfavorable Characteristics Subscore: ____ (14 possible) E. Medication Trial Subscore ____ (10 possible) Total Scale Score (C+D+E): ____ (34 possible) Presence of Refractory Tremor:
Yes/No (Presence of moderate to severe tremor that is refractory to high doses and combinations of levodopa, dopamine agonists, and anticholinergics may be an indication for surgery in some candidates, independent of their score on the remainder of the questionnaire)

Source: https://com-movement-disorders.sites.medinfo.ufl.edu/files/2009/04/UniversityofFloridaDBSFastTrackNetwork.pdf