Effective date: __________________________

INFORMATION FOR MEDICAL CARE AND ASSESSMENT

My full name is ______________________________________

Address:____________________________________________

Phone: __________________

Insurance Info: __________________________________

Phone: __________

Social Security No. ______________________

Date of Birth: _________________

DOCTORS:

I was diagnosed with Parkinson’s disease in ________. (Year) It is important to have a neurologist/doctor familiar with my condition.

Family doctor: ____________________ Phone: ________

Neurologist: _________________________ Phone: ________

Other:_____________________________ Phone: ________

EMERGENCY INFORMATION:

Blood type: ___________

Allergies: ___________________________________________

Please contact:

Name:_________________________________

Address: _________________________

Phone:_________________________

Name:__________________________________

Address _________________________

Phone:_________________________

Name:__________________________________

Address: _________________________

Phone:_________________________

MEDICATIONS:

I must be given my medication promptly at the times specified. If this is not possible, consult my admitting physician for authorization to administer my own medication or alternatively, have it administered by my CareGiver. The timing of my medication is very important to help my “off” times. Following are all prescription and over-the-counter drugs I currently take.

Medication	Strength	Time Taken

Possible Side Effects: nausea, dizziness, mental changes, confusion, hallucinations, involuntary movements, loss of appetite, dryness of mouth, lowered blood pressure.

If I am on Eldepryl, I MUST NOT BE GIVEN DEMEROL.

Eldepryl with Demerol can be deadly! To be safe, Eldepryl should not be taken for a period prior to taking Demerol. It is imperative that my attending physicians verify and stipulate this interval. A number of other drugs may be contraindicated with some I take, please check it carefully.

ADDITIONAL CONCERNS/COMMENTS/CONDITIONS for which I am being treated:

___________________________________________

____________________________________________

____________________________________________

____________________________________________




WHAT IS PARKINSON’S DISEASE? Parkinson’s disease is a slowly progressive disorder due to the accelerated loss of the brain chemical dopamine (a neuro-transmitter) that activates the message system controlling movement. Its symptoms are tremors, rigidity, slowed gait and balance impairment (which may resemble intoxication, but is not). These worsen and lessen several times a day in “on-off” cycles. It is important that those who care for me outside of my home have a basic understanding of the disease so that observations and impressions can be accurately treated as characteristics of Parkinson’s and not as personal behavior traits. Please note that stress, anxiety, lack of exercise and/or the need for rest may worsen my condition. Therefore, I HAVE CIRCLED PERTINENT INFORMATION AND MY SPECIFIC SYMPTOMS:

Name: _______________________ Room ______ Bed______

MEDICATION Administer Parkinson medication EXACTLY on schedule. Without medicine I may become rigid and disoriented. Response to medication may affect physical therapy timing.

AMBULATION Have difficulty with balance, stooped posture, swollen feet. Difficulty walking (a decrease in natural arm swing, short shuffling steps, difficulty turning). May freeze and fall. Require help getting started and walking. Dizziness. “On-off” symptoms (able to perform one minute, but not the next— which may be related to timing of medications.)

ELIMINATION Urinary problems (hesitancy, frequency, inability to wait, or incontinence.) Suffer from constipation, need special diet or other treatment. Impaction is a significant danger.

COORDINATION Tremor, rigidity (cannot open food or other containers easily). Cannot always repeat a former action. May not have strength to push call button. Have slow responses. Have trouble turning in bed. Dyskinesias (involuntary, unwanted, writhing movements) caused by sensitivity & over-medication-not to get attention.

COMMUNICATION Speech problems: low voice volume, slurred indistinct words. Face shows little or no emotion ("mask of Parkinson’s"). Depression and dementia from the disease.

EATING & SWALLOWING Difficulty swallowing. Choke on food. Very slow eater. Need special diet due to the effect protein has on my medication. Drooling.

SLEEPING Trouble getting to sleep. Sleep fitfully. Have anxiety sweats.