Re: Hospital Form

[Bob & Joy Graham <bjgraham@xxxxxxxxxxxxxxxxx>]

HOSPITALISATION FORM

AS A PERSON WITH PARKINSON'S DISEASE I HAVE PROBLEMS
WITH THE ITEMS CHECKED BELOW

        Full
Name:.......................................................................
...............................


Doctor:......................................................Neurologist:...
............................................

        MEDICATION

o       1.  I need my Parkinson's medication administered EXACTLY on schedule.
o       2.  Without medication I will become rigid and disoriented.
o       3.  Response to medication may affect physical therapy timing.

        AMBULATION

o       4.  I have difficulty with balance.
o       5.  I may freeze and fall.
o       6.  I require help getting motion started and walking.

        ELIMINATION (underline specifics)

o       7.  I have urinary problems: either hesitancy, frequency, inability
to wait, or incontinence.
o       8.  I suffer from constipation, need a special diet or other
treatment.  Impaction is a significant danger.

        COORDINATION

o       9.  I cannot open food containers easily.
o       10.  I cannot always repeat a former action.
o       11.  I may not have the strength to push a call button.
o       12.  I have slow responses.
o       13.  I have trouble turning over in bed.

        COMMUNICATION

o       14.  I have low voice volume.
o       15.  I have difficulty enunciating.
o       16.  My face shows little or no emotion ("mask" of Parkinson's).
Do not misinterpret my lack of facial expression as an automatic indicator
of loss of cognitive ability.
o       17.  I have difficulty with writing

        EATING AND SWALLOWING

o       18.  I choke on food and require a special diet.
o       19  I am a very slow eater.

        SLEEPING

o       20.  I have trouble getting to sleep.
o       21.  I sleep fitfully.
o       22.  I have anxiety sweats

        ON-OFF PROBLEMS

o       24.  Due to the "on/off" syndrome, I am often unable to do things
which I could do earlier.

Adapted from an original list designed by Beverly Steward, by the
Parkinson's Association of WA for use by members and others with
Parkinson's Disease.

Attachment: Hospitalisation_form_-2.doc
Description: Mac BinHex archive