This survey will help us to show how many people are suffering due to the side effects of Mirapex and other agonists. THIIS CONFIDENTIAL. If you do not want to give your name please put in a fictitious one. We would like to be able to contact you by E-mail but again respect your privacy here as well. If you do not wish to supply a valid e-mail simply type in "anon@anon.com". Thank-you for your help!

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Name *
E-mail Address *
Country where you live *	United StatesAbu Dhabi AfghanistanAfrican UnionAlbaniaAlberta (Canada)AlderneyAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArab LeagueArgentinaArmeniaArubaASEANAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutánBoliviaBonaire (Netherlands Antilles)Bosnia & HerzegovinaBosniac-Croat Federation BotswanaBrazilBritish Antarctic TerritoryBritish Columbia (Canada)British Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurma BurundiCambodiaCameroonCanadaCape VerdeCARICOMCayman IslandsCentral African RepublicChadChileChinaChuuk (Truk) (Micronesia)CISCocos IslandsColombiaCommonwealthComorosCongo-BrazzavilleCongo-KinshasaCook IslandsCornwall St. Pirran’s Cross (United Kingdom)Corsica (France)Costa RicaCôte d’IvoireCroatiaCubaCuraçao (Netherlands Antilles)CyprusThe Czech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (see Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropean UnionFalkland IslandsThe FaröesFIAVFijiFinlandFranceFrench Guiana (France)French PolynesiaFrench Southern & Antarctic LandsGabonGambiaGeorgiaGermanyGhanaGibraltarGreat Britain GreeceGreenlandGrenadaGuamGuatemalaGuernseyGuineaGuyanaHaitiHeard & McDonald IslandsHolland Holy See HondurasHungaryIcelandIndiaIndonesiaIrânIraqIrelandIslamic ConferenceIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartinique (France)MauritaniaMauritiusMayotteMéxicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontenegro (Serbia & Montenegro)MontserratMoroccoMozambiqueMyanmarNamibiaNATONauruNepalhe NetherlandsNetherlands AntillesNew CaledoniaNew ZealandNewfoundland NicaraguaNigerNigeriaNiueNordic CouncilNorth KoreaNorthern CyprusNorthern IrelandNorthern MarianasNorwayNova Scotia OASOlympic MovementOmanOntario (Canada)OPECPacific CommunityPakistanPalauPalestinePanamáPapua New GuineaParaguayPerúPhilippinesPitcairn IslandsPohnpei (Ponape) (Micronesia)PolandPortugalPrince Edward Island (Canada)Puerto RicoQatarQuébec (Canada)Red CrossRomâniaRussian FederationRwandaSaba (Netherlands Antilles)St. Helena & DependenciesSt. Kitts & NevisSaint LuciaSt. Maarten (Netherlands Antilles)St. Patrick’s Cross (United Kingdom)St. Pierre & MiquelonSt. Vincent & the GrenadinesSamiSamoaSan MarinoSão Tomé & PríncipeSarkSaskatchewan (Canada)Saudi ArabiaSeborgaSenegalSerbia (Serbia & Montenegro)Serbia & MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSovereign Military Order of MaltaSpainSri LankaThe SudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTibetTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTromelinTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited NationsUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaViêt NamVirgin IslandsVojvodina (Serbia & Montenegro)Wake IslandWallis & FutunaWestern European UnionWestern SaharaYap (Micronesia)YemenZaïre ZambiaZimbabweZuid-Holland
If U.S., State where you live *	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
City where you live *
Current Age *
Sex *	MaleFemale
Date diagnosed with Parkinson's or other related disorder *
Which drug(s) were(are) you taking while experiencing side effects? *
Approximate dates you took the drug, ie 4/1995 - 6/2006
Did any friends or family comment on your behavior? *	YESNO
If yes, what were their comments?
Did your doctor warn you about any side effects of the drug before prescribing it? *	YESNO
If "YES" what side effects were you warned about?
What side effects did you experience?	Hypersexuality
	Excessive Gambling
	Online or Indescriminate Sex
	Excessive Shopping Sprees
	Withdrawel From Friends or Family
	Drastic Personality Change
	Compulsive Eating
	Alcohol Abuse
	Drug Abuse
	Suicidal Feelings or a Suicide Attempt
	Extreme Rage or unchacteristic violence
	Other Compulsive Behavior
If you checked "Other Compulsive behavior", please describe
If you have stopped the drug did the behaviors Stop Too?	Not ApplicableYESNO
How soon after stopping the drug did the behaviors stop?
iF YOU WERE ON MIRAPEX WHAT WAS THE DOSE AND INCREASES, IF ANY.
Did behaviors coincide with a dose incease?	YES NO
Did you ever tell your doctor about any of the behaviors or side effects?	Not ApplicableYESNO
If "YES" what was the doctors response?
If you went back on the drug, did the behaviors return?	Not ApplicableYesNo
I have read and agree to the Privacy Policy *

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