Periodic Paralysis News Desk

Name:

D.o.B.

Allergies:

Medications:

Date:

HKPP:

Under “Surgical History” please list all operations/procedures as well as dates, Under “Medical History” please list all medical conditions/syndromes as well as dates of diagnosis. Under “Handicaps” please list all assistive devices required (cane, splints, wheelchair, etc).

Surgical History

Medical History

Handicap aids

Body Systems Assessment

Vital Signs:

Blood pressure: sitting StandingLying

Heart Rate (Pulse): Regular Irregular

Respiratory Rate (breaths per minute):

Temperature:

Neuro History

Headaches (Y/N)

Type: Migraine Cluster Tension

Frequency

Duration

Symptoms

Precipitating Events

Treatment

Ptosis (droopy eyelid) (Y/N)

Details

Difficulty Focusing (Y/N)

Details

Cardio-Vascular Accident - CVA/Stroke (Y/N) Type

Transient Ischemic Attack - TIA (Y/N)

Syncopal Episode - Fainting (Y/N)

Frequency

Duration

Symptoms

Precipitating Events

Treatment

Residual Effects

Other (Specify)

Cardio-Vascular History

Coronary Artery Disease - CAD (Y/N)

Congestive Heart Failure - CHF (Y/N)

Cardiomyopathy (Y/N)

Pacemaker (Y/N) Type

Cardiac Stent (Y/N) Location

Arrhythmias (Y/N)

Type

Frequency

Duration

Symptoms

Precipitating Events

Treatment

Oxygen Therapy (Y/N)

Details

Palpitations (Y/N)

Details

Chest Pain (Y/N)

Type

Frequency

Radiation (arms, neck jaw, etc)

Duration

Precipitating Events

Treatment

EKG/ECG (Y/N) Copy Available (Y/N)

Date Most Recent

Findings

Cardiac Stress Test (Y/N) Copy Available (Y/N)

Date Most Recent

Findings

High Cholesterol (Y/N)

Last Cholesterol Level

Last HDL

Last LDL

Last Triglyceride Level

Peripheral Vascular Disease (Y/N)

Details

Varicose Veins (Y/N)

Details

Neuropathy (Y/N)

Details

Other (Specify)

Respiratory History

Smoking (Y/N)

How many per day

For how many years

Used to Smoke (Y/N)

For how many years

Asthma (Y/N)

Details

Emphysema (Y/N)

Details

Shortness of Breath (Y/N)

Occurrence (at rest, exertion,etc.)

Frequency

Duration

Symptoms

Precipitating Events

Treatment

Use a Nebulizer (Y/N)

Details

Use Oxygen Cylinder (Y/N)

Details

Respiratory Arrest Needing Ventilation (Y/N)

Details

Other (Specify)

Gastro Intestinal History

Special Diet - Food allergies, Celiac Disease, Diabetic, Lactose Intolerant etc (Y/N)

Details

Hiatus Hernia (Y/N)

Bowel Pattern: Regular DiarrheaConstipation

Details

Colonoscopy (Y/N) Date

Findings

Gastric Ulcer (Y/N) Type

Symptoms

Duration

Precipitating Events

Treatment

Irritable Bowel Syndrome (Y/N)

Symptoms

Duration

Precipitating Events

Treatment

Hemorrhoids (Y/N) Blood in Stools (Y/N)

Details

Recent Weight Change: Loss (Y/N) Gain (Y/N)

Details

Adverse Reaction to Foods (Y/N)

Details

Other (Specify)

Genito-Urinary History

Bladder Problems:

Frequency Incontinence Retention

Details

Renal Insufficiency (Y/N) Renal Failure (Y/N)

Dialysis (Y/N)

Details

Fluid Restriction (Y/N)

Men

Prostate Problems (Y/N)

Details

Women

Menstruation Problems (Y/N)

Details

Menopausal (Y/N)

Post Menopausal (Y/N)

Hormone Replacements Therapy (Y/N)

Oral Contraceptive Pill (Y/N)

Other contraceptive Devices (Y/N)

Details

Other (Specify)

Skin

Skin Cancer (Y/N)

Type: BCC, SCC, Melanoma

Details

Rash (Y/N) Burn (Y/N) Birth Marks (Y/N)

Moles (Y/N) Lesions (Y/N)

Details

Dermatitis (Y/N)

Frequency

Duration

Precipitating Events

Treatment

Broken Areas on Skin (Y/N) Bruise Easily (Y/N)

Other (Specify)

Musculo-Skelital History

Muscle Pain

Frequency

Duration

Muscles Involved

Precipitating Events

Treatment

Stiffness

Frequency

Duration

Muscles Involved

Precipitating Events

Treatment

Weakness

Frequency

Duration

Muscles Involved

Precipitating Events

Treatment

Paralysis

Frequency

Duration

Muscles Involved

Precipitating Events

Treatment

Preeminent Muscle Weakness (Y/N)

Description

Muscle Biopsy (Y/N) Date

Findings

Involuntary muscle movement (Y/N)

Description

Fatigue (Y/N)

Description

Abortive Attacks

Frequency

Duration

Intensity

Symptoms

Precipitating Events

Treatment

Other (Specify)

Please use the area below to document any information that you believe will be of assistance to the members of the health care team.