DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM

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Transcription:

Name: MR#: Date: DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM Referring Physician s Name: Primary Care Provider s Name: 1. What was/were your first movement disorder symptoms? What did you or your family first notice before being diagnosed with your movement disorder? 2. What year were you first diagnosed with Parkinson s Disease/ Essential Tremor/ Dystonia? 3. Which side of your body was first affected? (Circle One) Left or Right 4. Which of the following best describes your current state: (Circle One) a) One side of my body is slightly worse than the other side. b) One side of my body is moderately worse than the other side. c) One side of my body is severely worse than the other side. d) Both sides affect me the same. Can not say one side is worse. 5. Please check the box that best describes your current state: Symptoms (in OFF period except where indicated) ne Minor Major Do these symptoms improve during ON period? a) Tremor b) Rigidity (stiffness) c) Dystonia (muscle cramping pain) d) Bradykinesia (slow movement) e) Gait disorder (walking difficulty, freezing) f) Postural instability (balance difficulty) g) Speech problems h) Swallowing problems i) Memory loss j) Hallucinations on meds k) Dyskinesia (extra involuntary movements) on meds 6. How would you rate your difference between your best ON state and your worst OFF state? a) Extreme b) Moderate c) Slight d) ne 7. Approximately what percent of your waking daytime is spent in the ON state? %

8. What bothers you the most about having Parkinson s disease/ Essential Tremor/ Dystonia? Describe. 9. If you were to have surgery for your movement disorder, what benefits are you hoping for after surgery? 10. Have you ever had brain surgery? a) b) What procedure? When? 11. How would you rate your level of knowledge regarding surgeries for movement disorders? a) Little or ne b) Moderate c) Extensive 12. Where did you learn about surgeries for movement disorders? a) Discussion with MD b) Support Group/Seminars c) TV/Newspaper d) Internet e) Other: 13. Allergies? 14. When was your last change in medication regimen? 16. How long does it take for your movement disorder medications to START working after you take each dose? 17. How long does each dose of medications usually last before its effects wear off? 18. How do you feel first thing in the morning before you take your medications? OFF or ON 19. Current Medications: Medication Name Strength

20. Do you have trouble with sleep? (circle one) Too sleepy t enough sleep 21. How would you rate your mood? (circle one) Happy Occasionally sad Often sad Very sad all the time 22. Have you ever been diagnosed with any of the following? High blood pressure Diabetes Heart attack Heart failure Stroke Blood vessel disease Tuberculosis Hepatitis. Date of Onset or Duration Cancer Respiratory Bleeding problems Leg clots Peptic ulcer disease/reflux Renal (kidney stones) Arthritis Other:. Date of Onset or Duration 23. FEMALES Pregnancies, how many? Deliveries, how many? C-sections, how many? Complications of pregnancy? Could you be pregnant now? Date of last normal period? 24. OPERATIONS: Please list surgeries you have had with date if known: 25. FAMILY HISTORY: List disease(s) that tend to run in the family. (diabetes, high blood pressure, heart attacks, strokes, cancer, etc ) Family Member Living? Age Medical Disease Mother Father Siblings: Children:

26. SOCIAL HISTORY (circle all that apply or fill in blank) Do you smoke: Cigar? Cigarettes? Pipe? Packs per day? How many years? Do you drink alcohol? Type? How much? How often? Do you use recreational drugs? Type? Frequency? Last used: What type of work do you do, or have you done most of your life? Are you retired? What best describes your living situation? a) Lives alone with little support b) Lives alone with close support c) Lives with family d) Other: Do you need assistance with walking? a) Never b) Only when OFF c) Usually d) Always What type of assistive device(s) do you use? a) ne b) Holding on to someone, railing, walls, or furniture c) Cane d) Walker e) Wheelchair 27. REVIEW OF SYSTEMS: Please circle either YES or NO for each questions below: General: Weight gain/loss > 5lbs over the last several months? Loss of appetite? Fever or chills?... Feel weak and tired? Skin: Do you have rashes, bruises? Skin discolorations?. Bleeding/easy bruising tendancy? Head: Do you have tenderness?.. Lumps or masses?. Eyes: Pain or discharge?.. Change in vision?.. Ears: Hearing problems? Pain or discharge?.. se: Frequent nose bleeds?. Trouble breathing through nose? Pain or discharge?... Mouth & Throat: Dental disease?. Hoarseness or voice changes?. Sore throat or other pain? Lumps, masses, discharge?. Respiratory: Short of breath on exertion? Walk 2 flights of stairs without significant discomfort?. Have frequent yellow or green sputum? Cough up blood?. Cardiovascular: Chest pain, chest tightness, or angina on exertion?. Chronic ankle swelling?.. Can you sleep flat in bed? Do you wake up at night short of breath? Gastrointestinal: Nausea or vomiting?. Diarrhea or constipation?. Black tarry stools or bloody stools?.. Heartburn or reflux?.. Genitourinary: Cloudy or bloody urine?.. Burning on urination?.. Get up several times at night to urinate?.. Men: Hard to initiate/maintain urination? Central Nervous Systems: Any seizures? Severe headaches? Loss of strength or sensation?.. Memory changes?.

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