NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

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1 NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician: Date of Birth: Handedness: Right Left Other: Do you have any of the symptoms listed below? Please circle all that apply. Trouble walking Falls Feet sticking to the floor Tremor Medications wearing off Trouble sleeping Vivid dreams Trashing and talking in sleep Daytime sleepiness Compulsive behaviors such as excessive gambling, eating, shopping or sex Fever Chills Sweats Weakness Fatigue Changes in vision Discharge from your eyes Blurred vision Double vision Trouble breathing Cough Coughing up blood Wheezing Dusky skin color Chest pain Heart palpitations Leg swelling Fainting Light-headedness Nausea Vomiting Diarrhea Constipation Heartburn Abdominal pain Painful urination Blood in urine Incontinence Easy bruising Easy bleeding Swollen lymph glands Excessive thirst or hunger Cold intolerance Heat intolerance Back pain Joint pain Muscle pain Decreased range of motion Injury Rash Itching Skin breakdown Burns Skin lesions Anxiety Depression Suicidal thoughts Hallucinations Confusion Memory changes Which symptom bothers you most? Physical Address: NE 128th Street Suite #300 Kirkland WA Tel: Fax: Mailing Address: NE 128th Street MS #11 Kirkland WA Rev:

2 What were your earliest symptom(s)? When did they start? List All Medical Diagnoses: List Surgeries: Does any family member have Parkinson s disease, tremor, or other nerve disorder? If so, who? Exposure Dates of Exposure (month/year month/year) Quantity Smoking / - / packs per day Alcohol / - / drinks per day Caffeinated coffee / - / cups per day Drugs / - / Intravenous/Oral Well water / - / N/A Pesticides / - / N/A Welding / - / N/A Head injury No. of injuries Comment Are you retired? Yes No What is/was your occupation? Marital Status: Do you live alone? Yes No Do you live in an assisted care home or nursing home? Yes No

3 (Please bring this completed medication sheet to your first visit) Parkinson s or movement medicine Morning PM Afternoon/Evening Night Med Name & strength Example: Sinemet 25/100 List number of tablets taken under each hour Other Medicine Morning PM Afternoon/Evening Night Med Name & strength (Please bring this completed medication sheet to your first visit)

4 Vitamins & Supplements Name of vitamin Strength (mcg, mg or IUs) PM Please note medications that you have previously taken for your movement disorder: Medication Date(s) taken Reason for stopping List any drug allergies: Drug What kind of reaction did you have?

5 Severity of Symptoms Rating Scale Please rate the severity of your symptoms on a scale from 0 to 5 with 5 being the most severe or most worrisome problem (circle one number for each problem). 0 = No problem or no concern 5 = Severe problem or biggest concern Writing Fine hand movements Bathing, dressing Walking Falls Freezing Dyskinesia/extra movements Muscle spasm Medicine wearing off Speech Swallowing Sleep Depression Anxiety Motivation Thinking Hallucinations Pain Constipation Bladder Light-headedness Sexual function Are you interested in participating in clinical trials? Yes No Have you had blood work, brain MRI or CT scan? Yes No Have you ever seen a Physical Therapist for your condition? Yes No Have you ever seen an Occupational Therapist for your condition? Yes No Have you ever seen a Speech Therapist for your condition? Yes No

6 Hobbies: List your hobbies and/or interests: Which hobbies are you no longer doing? Exercise: Do you exercise now? If so, what do you do, for how long and how frequently? Did you exercise before your symptoms began? If so, what did you do, for how long, and how frequently? CHECKLIST FOR YOUR VISITS

7 Use this checklist to assist you with your visits. Remember, these steps take work; however, they will help you gain the most you can out of your medical visits. o Take a patient questionnaire home with you after each visit. Fill it out in advance of your appointment. Please be complete. Please do not use statements like no changes, same as last visit or the doctor knows what I am taking. o Keep your own list of medications: include name, strength, timing, generic or trade. Also include prior medicines that were either tried and not effective or caused side effects that resulted in discontinuation. o Keep a list of all of your treating physicians: include name, address and fax # o Keep a list of any changes that result from calls to your physician between appointments. o Keep track of your medication needs so you do not run out. o Keep a list of new medical problems, medications or new living arrangements. Please list the name and address of any physician to whom you would like a copy of our reports sent: Name Address City State Zip Reviewed and discussed with patient: Date:

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