Health Problem

Changes

Seizure disorder

When were you told that you have a seizure disorder?

What type of seizures do you have?

  Tonic-clonic (grand mal)?

  Partial?

  Absence?

How often do you have a seizure?

  When was the last one?

  Does your family know what to do if/when you have a seizure?

What medicine do you take for the seizures?

  How often do you take it?

  Do you have to have blood work done because of your medicine?

  When was the blood work last done?

When are you supposed to see your doctor or health care provider again for the seizures?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the seizures?

Stroke

When did you have the stroke?

What side of the body did the stroke affect?

What weakness are you still experiencing?

What other problems are you having because of the stroke, such as:

  Problems eating and swallowing?

  Controlling bowels/bladder?

  Walking/balance?

What do you use, if anything, for safety when walking?

What medicine have you been taking since the stroke?

  How often do you take it?

  Do you need to have blood work done because of the medicine?

When are you supposed to see your doctor or health care provider again for the stroke?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the stroke?

Concussion

When did you have the head injury?

What were you doing when you had the injury?

  Sports activity?

  Motor vehicle accident?

  Fall?

What symptoms are you experiencing because of the injury?

Are you taking any medicine because of the injury? If so,

  What is the name of the medicine?

  How often do you take it?

Are you having any kind of therapy because of the injury, such as

  Physical therapy?

  Occupational therapy?

When are you supposed to see your doctor or health care provider again for the injury?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the injury?

Headaches

What type of headaches do you have?

  Tension?

  Migraine?

  Cluster?

How often do they occur?

What symptoms do you have with the headaches, such as:

  Pain in the neck/shoulders (tension)?

  Eye pain and tearing (cluster)?

  Photophobia, nausea, vomiting (migraine)?

What medicine are you taking for the headaches?

  How often do you take the medicine?

  Is the medicine effective?

Is there anything that you were told to do to help prevent the headaches, such as:

  Increasing activity/exercise (tension)?

  Avoid alcohol, chocolate, caffeine (migraine)?

  Smoking cessation?

Has avoiding these things helped?

When are you supposed to see your doctor or health care provider again for the headaches?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the headaches?

Spinal cord injury/nerve compression

When did you have the injury?

What symptoms are you having now/still experiencing, such as:

  Numbness?

  Tingling?

  Paralysis?

Do you have any other problems that were caused by the injury, such as:

  Problems with your bowels or bladder?

  Muscle cramping?

Were you prescribed any medicine to help with the symptoms of the injury? If so,

  What is the name of the medicine?

  How often do you take it?

  Has it been effective to control the symptoms?

When are you supposed to see your doctor or health care provider again for the injury/nerve compression?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the injury/nerve compression?

Herniated disk/back surgery

When did you have the herniated disk/back surgery?

What symptoms are you having right now, such as:

  Pain?

  Spasms?

  Muscle weakness?

What medicine are you taking for the problem?

  Is the medicine effective?

What else have you been prescribed for the problem, such as:

  Physical therapy?

  Water therapy?

  Transcutaneous electrical nerve stimulation (TENS) unit?

  Back brace?

  Smoking cessation?

  Weight reduction/management?

When are you supposed to see your doctor or health care provider again for the disk injury/back surgery?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the disk injury/back surgery?

Multiple sclerosis

When were you told you have multiple sclerosis?

What symptoms do you have right now, such as:

  Vision changes?

  Problems walking or using your hands?

  Problems with bowel/bladder control?

  Overall weakness?

What do you use for help with self-care and mobility, such as:

  Splints?

  Walker?

  Wheelchair?

What else were you told to do to help with the symptoms, such as:

  Frequent rest periods?

  Avoid extremes in temperature?

  Weight management?

What medicine do you take for the symptoms?

  Is the medicine effective?

When are you supposed to see your doctor or health care provider again for the health problem?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the health problem?

Parkinson’s disease

When were you told that you have this disorder?

What symptoms are you having now, such as:

  Hand tremor?

  Stiffness of the arms and legs?

  Problems with walking?

Are you having any problems with:

  Eating?

  Swallowing?

  Breathing?

  Sweating?

  Having bowel movements?

What medicine do you take for the health problem?

  How often do you take it?

  Has it helped with your health problem?

When are you supposed to see your doctor or health care provider again for the health problem?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the health problem?

Myasthenia gravis

When were you told that you have myasthenia gravis?

What symptoms are you having right now, such as:

  Difficulty talking?

  Problems with swallowing?

  Weak voice?

  Difficulty writing or doing other activities with the hands?

Were you told to do anything else to help with the symptoms, such as:

  Avoiding extreme temperatures?

  Getting enough rest?

What medicine are you taking for the health problem?

  How often do you take it?

  Do you keep a supply of extra doses in your (purse, pocket)?

  What happens if you take too much of the medicine?

      What are you supposed to do if that happens?

  What happens if you miss a dose or several doses of the medicine?

      What are you supposed to do if that happens?

When are you supposed to see your doctor or health care provider again for the health problem?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the health problem?

Trigeminal neuralgia/tic douloureux

When were you told you have this problem?

What symptoms are you having right now, such as:

  Eye tearing?

  Eye pain?

  Face/jaw pain?

What treatment have you had for the problem, such as:

  Surgery?

  Medication?

If you are taking medication, how effective has it been?

When are you supposed to see your doctor or health care provider again for the health problem?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the health problem?

Bell’s palsy/facial paralysis

When were you told that you have facial paralysis/Bell’s palsy?

What symptoms are you having right now, such as:

  Continued facial weakness?

  Problems closing the eye on the side of the face with the weakness?

What have you been told to do for the symptoms, such as:

  Massage the face muscles?

  Apply warm compresses to the face?

  Use artificial tears in the eyes?

  Eat a soft diet?

  Perform facial exercises?

When are you supposed to see your doctor or health care provider again for the paralysis?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the paralysis?

Cataracts

Where were you told that you have a cataract?

What symptoms are you experiencing right now, such as:

  Cloudy vision?

  Glare?

  Problems seeing the color blue?

When are you having surgery to remove the cataract?

If postoperative: When did you have the surgery to remove the cataract?

  What eye drops are you taking after the surgery?

  Did you have a lens implanted with the surgery?

  When are you supposed to see the doctor again after the surgery?

Were you told that you have a cataract developing in your other eye?

Were you told when you might need surgery on the cataract in the other eye?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the cataract?

Glaucoma

When were you told that you have glaucoma?

What symptoms are you having right now, such as:

  Reduced vision?

  Eye pain?

What medicine are you taking for the glaucoma?

Are you going to have/had surgery for the glaucoma?

  When is it going to be done/when was it done?

  If postoperative: What changes have you noticed in your vision since the surgery?

When are you supposed to see your doctor or health care provider again for the glaucoma?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the glaucoma?

Macular degeneration

When were you told that you have macular degeneration?

What type were you told that you have:

  Wet?

  Dry?

What symptoms do you have right now such as:

  Blurry central vision in one/both eyes?

  No changes to peripheral vision?

Are you using any eye drops/medicine because of the problem?

  Have you noticed if the eye drops have made any difference in your vision?

Are you planning to have/had surgery for the macular degeneration?

  When is the surgery scheduled/when did you have the surgery?

  If postoperative: have you noticed any changes in your vision since the surgery?

When are you supposed to see your doctor or health care provider again for the macular degeneration?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the macular degeneration?

Detached retina

When were you told that you had a detached retina?

What were you doing when it happened?

When did you have surgery to repair the retina?

  Do you know the type of surgery that you had?

How is your vision right now?

Are you having any other problems caused by the detached retina, such as:

  Floaters?

  Transient blindness?

  Loss of central vision?

When are you supposed to see your doctor or health care provider again for the detached retina?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the detached retina?

Deafness/hearing loss

When were you told/when did you first start to notice problems with your hearing?

Were you told what type of hearing loss you have?

  Sensory?

  Conductive?

  Both?

Do you have any other symptoms with the hearing loss, such as:

  Nausea/vomiting?

  Dizziness?

What treatments have you had to help with the hearing loss, such as:

  Ear irrigation?

What type of hearing aid do you use?

  How often do you need to change the batteries in the device(s)?

Are you able to insert and remove the hearing aids yourself or do you need assistance?

When are you supposed to see your doctor or health care provider again for the hearing problem?

For what reasons have you been directed by your doctor or health care provider to seek additional medical care because of the hearing problem?