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DOD State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Registration
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Are you currently represented by an attorney?
Yes
No
Did/Do you have a restricted use pesticide license, or are you a certified pesticide applicator?
Yes
No
Did/do you work for a person who had a restricted use pesticide license?
Yes
No
Are you willing to sign an Affidavit stating you were exposed to Paraquat?
Yes
No
Registration
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Were you exposed to paraquat, or tho-paraquat or gramaxone?
Yes
No
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Diagnosed with PD?
Yes
No
PD Motor Symptoms
Hand tremors
Prolonged or extreme stiffness
Difficulty with body movements
Loss of balance
Difficulty Walking (slow gait, shuffling)
Difficulty or soft speaking
Reduced facial expression
Blank stare
Drooling
Small handwriting
Trembling
Whole body fatigue or dizziness
Amnesia or confusion in evening hours
Early awakenings or sleep disturbances
Anxiety or apathy
Other symptoms
PD Medications
Amantadine
Apokyn (apmorphie hydrocholride injection)
Artane (trihexyphenidyl HCL)
Axilect (rasagiline)
Cogentin (benztropine)
Elepryl (selegiline)
KYNMOBI (Apomorphine hydrochloride)
Sinemet (levodopa)
Mirapex (pramipexole)
Neupro (Rotigotine Transdermal System)
Nourizanz (istradefylline)
Requip (ropinirole)
Xadago (safinamide)
Zelapar (Selegiline HCL orally disintegrating)
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Do you have a neurologist or movement disorder specialist?
Yes
No
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Registration
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Case Type
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