Do you have any of the symptoms listed below? Please circle all that apply.
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- Rosa Lambert
- 6 years ago
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1 D yu have any f the symptms listed belw? Please circle all that apply. Parkinsn s Symptms: Truble walking Falls Feet sticking t the flr Tremr Medicatins wearing ff Truble sleeping Vivid dreams Thrashing and talking in sleep Daytime sleepiness Cmpulsive behavirs such as excessive gambling, eating, shpping r sex General Symptms: Fever Chills Sweats Weakness Fatigue Recent visual prblem Discharge frm yur eyes Blurred visin Duble visin Shrtness f breath Cugh Cughing up bld Wheezing Dusky skin clr Chest pain Heart palpitatins Leg swelling Fainting Light-headedness Nausea Vmiting Diarrhea Cnstipatin Heartburn Abdminal pain Painful urinatin Bld in urine Incntinence Easy bruising Easy bleeding Swllen lymph glands Excessive thirst Cld intlerance Heat intlerance Excessive hunger Back pain Jint pain Muscle pain Decreased range f mtin Injury Rash Itching Skin breakdwn Burns Skin lesins Anxiety Depressin Suicidal thughts Hallucinatins Cnfusin Memry changes Apprved 05/17 Page 1 f 6
2 Which symptm bthers yu mst? What were yur earliest symptm(s)? When did they start? List All Medical Diagnses: List Surgeries: Family Member/Relatin: Significant Medical Cnditin(s): Expsure Dates f Expsure (mnth/year mnth/year) Quantity Smking / - / packs per day Alchl / - / drinks per day Caffeinated cffee / - / cups per day Drugs / - / Intravenus/Oral Well water / - / N/A Pesticides / - / N/A Welding / - / N/A Head injury N. f injuries Cmment Are yu retired? Yes N What is/was yur ccupatin? Marital Status: D yu live alne? Yes N D yu live in an assisted care hme r nursing hme? Yes N Apprved 05/17 Page 2 f 6
3 Parkinsn s r mvement medicine Mrning PM Afternn/Evening Night Med Name & strength Example: Sinemet 25/100 List number f tablets taken under each hur Other Medicine Mrning PM Afternn/Evening Night Med Name & strength Apprved 05/17 Page 3 f 6
4 Vitamins & Supplements Name f vitamin Strength (mcg, mg r IUs) PM Please nte medicatins that yu have previusly taken fr yur mvement disrder: Medicatin Date(s) taken Reasn fr stpping List any drug allergies: Drug What kind f reactin did yu have? Apprved 05/17 Page 4 f 6
5 Severity f Symptms Rating Scale Please rate the severity f yur symptms n a scale frm 0 t 4 with 4 being the mst severe r mst wrrisme prblem (circle ne number fr each prblem). 0 = N prblem r n cncern 4 = Severe prblem r biggest cncern Prblems with Memry, Thinking, Fcus, etc Hallucinatins r Parania Depressin Anxiety Apathy (Lack f Mtivatin) Obsessive r Cmpulsive Behavir Sleep Daytime Sleepiness Pain Urinary Prblems Cnstipatin Light-headedness Fatigue (nt sleepiness) Speech Excess Saliva r Drling Swallwing Feeding Dressing Bathing & Persnal Hygiene Handwriting Ding Hbbies Turning Over in Bed Tremr Getting ut f Bed, Car r Chair Walking & Balance Freezing Duratin f Dyskinesias/Extra Mvement Severity f Dyskinesias Duratin f OFF Time Severity f OFF Time Unpredictability f OFF Time Muscle Spasms during OFF Time Apprved 05/17 Page 5 f 6
6 CHECKLIST FOR YOUR VISITS Use this checklist t assist yu with yur visits. Remember, these steps take wrk; hwever, they will help yu gain the mst yu can ut f yur medical visits. Take a patient questinnaire hme with yu after each visit. Fill it ut in advance f yur appintment. Please be cmplete. Please d nt use statements like n changes, same as last visit r the dctr knws what I am taking. Keep yur wn list f medicatins: include name, strength, timing, generic r trade. Als include prir medicines that were either tried and nt effective r caused side effects that resulted in discntinuatin. Keep a list f any changes that result frm calls t yur physician between appintments. Keep track f yur medicatin needs s yu d nt run ut. We require hurs t prcess refill requests. Keep a list f new medical prblems, medicatins r new living arrangements. We prefer each patient have an active Primary Care Prvider. It is imprtant t have a physician care partner fr issues that may nt be related t yur Mvement Disrder directly. Sign up fr EvergreenHealth Navigatr. This allws yu t cmmunicate electrnically with yur prvider and prvides nline access t yur medical recrd. Please list the name and address f any physician t whm yu wuld like a cpy f ur reprts sent: Name Address City State Zip Reviewed and discussed with patient: Date: Apprved 05/17 Page 6 f 6
Patient Information Packet Date:
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