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.
