Also forwarded on behalf of Joy Graham.
----------
> Date: Sunday, May 04, 1997 21:51:46
> From: Bob & Joy Graham
> To: Dennis Greene
> Subject: Hospitalisation Form
>
> Please could you send this to the List too. Thanks
>
> 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 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).
>
> EATING AND SWALLOWING
>
> o 17. I choke on food and require a special diet.
> o 18. I am a very slow eater.
>
> SLEEPING
>
> o 19. I have trouble getting to sleep.
> o 20. I sleep fitfully.
> o 21. I have anxiety sweats
>
> Adapted from a list by Beverly Steward (Central Ohio Parkinson Society
> Newsletter) which has been designed to make your stay in hospital as
> satisfactory as possible. It is important to explain to the nurses some
> significant facts about the way PD affects you. Ask to have this sheet
put
> in your file at the nurses' station. You might also consider having a
> close family member get a limited power of attorney to represent you, and
> if you have a Durable Power of Attorney, be sure the doctor and hospital
> have copies.
>
>
>
>
>
