Download sleep questionnaire - Consultants In Neurology

ConsultantsInNeurology.com
Raymond Rybicki M.D.
Sophos Geroulis M.D.
office: 262-631-8550 fax: 262-631-8557
Consultants in Neurology, S.C.
3805B Spring Street, Suite 120, Racine WI 53405
3601 30th Avenue, Suite 201, Kenosha WI 53144
____________________________________________________________________
MOVEMENT DISORDER
Date:
Name:
Age/DOB:
Occupation:
Chief Complaint:________________________________________________________
HPI:
1. Parkinson’s diagnosed: __________
2. Sinemet responsive: YES NO
3. Duration of Sinemet responsive
4. Parkinson symptoms:
a. Tremor: RUE LUE Both RLE LLE Both
b. Rigidity: YES NO
c. Balance Difficulties: Yes No
d. Bradykenesia: Yes No
e. On/Off: Yes No
f. Dyskenesias: Yes No
g. Drooling: Yes No
h. Micrographia: Yes No
i: Memory disturbance: Yes No
j. Hallucinations: Yes No
k. Orthostatic hypotension: Yes No
l. Sexual dysfunction: Yes No
m. Incontinence: Yes No
n. Other:
5. Main Parkinsonian problems not well controlled by medication:
PMHx: PSHx:
(Hospitalizations, surgeries, severe injuries)
Medications:
Past Medical History:
Cardiovascular disorders (heart disease):
Lung diseases:
Gastro-intestinal, liver, pancreas disorders:
Kidney and bladder disorders:
Endocrine disorders:
Musculo-skeletal disorders:
Neurological disorders:
Blood disorders:
Eyes:
Nose/throat/ears:
Infectious diseases:
Psychiatric disorders:
Hospitalizations:
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Surgeries:
Trauma to head with/without loss of consciousness:
Poisonings (food, chemical):
Exposure to chemicals (insecticides, pesticides, industrial solvents):
Exposure to infections (AIDS, syphilis, gonorrhea):
Birth History:
Was your mother’s pregnancy with you abnormal? Yes No
Was the labor and delivery abnormal (pre/post-term, complications?) Yes No
Were there any problems immediately after birth, during infancy or childhood:
High fevers: Yes
No
Meningitis or encephalitis: Yes No
Severe head or neck injury: Yes No
Seizures or epilepsy: Yes No
Stroke: Yes No
Developmental History:
Was there difficulty learning to walk? Yes No
How old were you when you took your first steps?______________________________
Did you have bodily deformity or abnormal curvature? Yes
No
Did you have any clumsiness, paralysis or weakness? Yes
No
Was there difficulty learning to talk? Yes No
How old?
Any difficulties with concentration or behavior in school?
Any areas of learning/reading disability?
Are you right- or left-handed or both (circle one:) Right Left
Do you write with (circle one)?: right left both
Do you eat with (circle one)?: right left both
Do you throw with (circle one)?: right left both
If right-handed, do you think you might be naturally left-handed (trained to use R instead of L)?
Do you have allergy/sensitivity to any medication?
List all medications you are currently taking:
Name Dose? How many times a day? For what purpose?
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________
4._____________________________________________________________________
5._____________________________________________________________________
6.____________________________________________________________________________
7.____________________________________________________________________________
8.____________________________________________________________________________
9.____________________________________________________________________________
List all medications you have tried:
Name Dose? How many times a day? For what purpose?
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
6.____________________________________________________________________________
7.____________________________________________________________________________
8.____________________________________________________________________________
9.____________________________________________________________________________
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Do you take any vitamin supplements or herbs?
Do you have a diet that includes fruit, vegetables, meat, milk and grains? If not, please
indicate any categories from which you rarely eat.
Family History:
If deceased, circle the age. Please explain and use additional paper if necessary.
Relative
Ages(s)
Name of any that has or had a neurological or muscular condition
Diagnosis or description of problem
Children
Brothers
Sisters
Father
Mother
Mother’s mother
Mother’s father
Mother’s brothers
Mother’s sisters
Father’s mother
Father’s father
Father’s brothers
Father’s sisters
Other relatives
Social History:
Martial status Children
Profession Disability (how long, reason)
Tobacco: How long? How many packs a day?
Alcohol: How long? How often? How much?
Recreational drugs: What kind? How often?
Review of systems:
Do you have any of the following symptoms?
Fevers
Weight loss/gain
Appetite increased/decreased
Cardiovascular:
-chest pain
-shortness of breath
-rhythm abnormalities (extra or skipped beats)
-high/low blood pressure
Lungs:
-breathing problems
-cough productive/non-productive
-sputum color
-urinary incontinence
Abdominal:
-nausea
-vomiting
-diarrhea/constipation
-pain
Urinary:
-frequency increased/decreased
-burning/painful urination
-blood in urine
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Musculo-skeletal:
-pain during movements
-decreased range of movements
-swelling of joints
-fractures
Eyes/ear problems:
Sleep difficulties:
Mood disorders:
-apathy (lack of interests)
-depression
Sexual difficulties:
MOVEMENT DISORDERS SECTION
Section 1.
Do you have tremor?
Which part is mainly involved?
-head/face
-hands
-legs
Does tremor disappear during active movements or sleep?
Do you have rigidity or stiffness?
Which part of the body is involved?
Do you have any of the following movement or gait/walking difficulties?
-slowing of movements
-clumsiness
-difficulties to start or stop walking (bumping into walls or objects)
-difficulties in turning around (causing loss of balance and falling)
-walking in small steps
-stooped posture when walking
-shuffling gait
Do you have any other symptoms?
-increased sweating
-drooling
-changes in writing: small-size handwriting
-speech difficulties, soft voice
-fatigue
-memory problems
-emotional lability
-depression
-sexual dysfunction
Section 2.
Do you have cramps or twisting movements of any part of the body?
-eyes
-neck
-hands/legs
-whole body
Have you noticed any unusual grimacing or tongue/mouth movements?
Is the cramp/twisting triggered by any activity?
Does the touching of the affected area decrease the cramp?
Is the cramp associated with pain?
Has the cramp/twisting progressed to involve other parts of the body?
What do you think started this disorder (trauma, drugs, toxins)?
Did you have Botox (botulinum toxin) treatment?
Did the treatment help you and for how long?
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Section 3.
Do you have any unusual type of movements; what kind?
Do you have brief, sudden movements, frequently repetitive and stereotypic such as:
-blinking
-head jerking or shaking
-nose twitching
-jumping
-kicking
-hitting
-throwing
-touching
Can you control them? How long?
Are you aware of any unusual noises that you make?
-throat clearing
-coughing
-grunting
-sneezing
-squeaking
-screaming
Do you feel urge to say obscene words?
Do you have brief, sudden shock-like jerks?
Do you have involuntary, continuous dance-like movements?
Do they interfere with your daily activities?
Did you notice any new memory problems?
Do you think that you have some difficulties to control your emotions?
Do you think you are compulsive? If so, why?
Do you think you are hyperactive? If so, why?
Section 4.
Have you been ever diagnosed with stroke or mini-stroke (TIA - transient ischemic attack)?
Have you had any of the following symptoms?
-weakness or paralysis of any part of the body
-decreased fine motor skills
-difficulties with coordination
-walking problems
-tingling or numbness of any part of the body
-slurred speech or lack of speech
-speech problems, such as difficulties word finding, misnaming objects
-hoarseness
-difficulties in swallowing
-double or blurred vision
-transient blindness
-visual field defects (difficulty with peripheral vision, loss of vision in any segment)
-dizziness or spinning accompanied by nausea and vomiting
-mental status changes
Were these symptoms transient or permanent?
Have you had tPA or heparin as a treatment for the stroke?
Are you taking currently?
Aspirin
Plavix/Clopidogrel
Ticlid
Coumadin/Warfarin
Aggrenox
Dipyridamole/Persantine
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Section 5. (Circle below if applicable)
Walking and Balance Problems?
-No complaints
-Diminished coordination in athletics or extraordinary activities
-Occasional stumbling or slipping in everyday activities but no device needed
-Frequent falls unless a straight cane is used
-Frequent falls unless a walker or fixed supporting object is used
-Confined to wheelchair
Section 6.
Do you have clumsiness of your hands? (Circle below which applies to you if any- If tremor
constant, skip this section)
-No complaints
-Only when performing unusually demanding activities or minor change in handwriting
-Occasional fumbling with ordinary activities but no practical disability
-Frequent fumbling causing difficulty with eating dressing writing or working, but you still do
these things routinely
-Severe fumbling causing many tasks to be avoided entirely; barely legible or illegible
handwriting; inability to eat in public; dressing
-Hands essentially useless
Section 7.
-Rhythmic Shaking of Hands (Circle below if applicable)
-No tremor
-On certain rare occasions or in some positions a temporary tremor occurs
-In everyday activities, a mild tremor occurs at times which does not interfere with any of the
activities
-In everyday activities, a tremor occurs which produces some interference with the activity (e.g.,
handwriting corrupted, coffee spilled, items dropped, etc.)
-A tremor is frequently present which is so severe that certain routine activities using that part of
the body are avoided entirely
-Very severe tremor which often renders the part of the body essentially unusable
Section 8.
Clarity of Speech? (Circle below if applicable)
-No complaints
-Occasional slurring or jumbling when speaking very rapidly or under pressure
-Occasional slurring during ordinary speaking but speech is fully understood
-Frequent slurring or jumbling such that speech is sometimes not understood
-Severe slurring or jumbling ordinary speaking such that speech is very often not understood
-Swallowing difficulties (list):
Section 9.
Clarity of Vision? (Circle below if applicable)
-No complaints
-Occasional difficulty focusing or fixating when under stress or looking at rapidly changing
images
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-Occasional difficulty fixating or focusing in everyday situations
-Cannot read but otherwise vision good enough to use in everyday life
-Severe problems with focusing or moving image frequently during day that interferes with many
different activities
-Focusing or fixation difficulties so great that there are always problems seeing everything
Section 10.
Fatigue? (Circle below if applicable)
-No complaints
-Exercise tolerance not as great as before, but everyday activities do no produce unusual fatigue
-Everyday activities cause more fatigue but daily routine not really changed
-Daily activities cause enough fatigue to cause daily schedule to be changed or strenuous
activities such as yard work, heavy cleaning eliminated
-Daily activities cause severe fatigue such that some everyday activities such as cooking,
washing dishes, house-cleaning, have been eliminated
-Essentially confined to movement from bed to chair and no occupational or household activities
Done
Section 11.
How has your job or work activity been affected by your movement disorder?
(Circle below if applicable)
-I have never been able to work
-I have only been able to work part-time
-It has interfered with or caused me to miss work
-I changed jobs because of the movement disorder
-I lost jobs because of the movement disorder
-No change has occurred due to the movement disorder
-I had already stopped working by the time the disorder started
Other:
What kind of diagnosis did you have for your movement disorder?
Did or does any of your blood relatives have a similar problems?
ADDITIONAL TESTS AND PROCEDURES
Have you ever had any of the following studies done?
CT brain/spine
MRI brain/spine
EEG
EMG/nerve condition study
LP – lumbar puncture
Carotid Doppler
ECHO
Genetic studies
Please obtain copy of relevant reports and bring CT/MRI films.
Who is your primary care physician (or physician referring you to GUH)?
Please give the name, address and telephone:
When was your last general medical examination?___________________________________
Was there any problems identified?_______________________________________________
Note: The physician who referred you to GUH will receive a copy of your medical report.
Please allow 2 to 3 weeks for you physician to receive the report. If you would like to request
a copy of your medical record, please contact us at 202-444-4972.
Weight:_________ Height:_________
Patient’s Signature:_______________________________Date:_____________________
Physician’s Signature:_____________________________Date:____________________
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