MEDICATION FORM OF YOUR NAME HERE Complete this form, make copies and keep them in your Aware in Care kit. At the hospital, share your completed Medication Form when you are asked to provide a list of medications. Fill out a new form when your prescriptions change and keep this updated version in your kit. Important names and numbers: Care Partner Relationship Phone/Fax Parkinson Doctor or Neurologist Phone/Fax Primary Care Physician Phone/Fax Pharmacy Phone/Fax Basic Information: I was diagnosed with Parkinson’s disease in (year). I have a Deep Brain Stimulation device. □ Yes □ No I also have the following conditions (check box): □Constipation □ □Depression □ □Heart □ Disease □Melanoma □ □Urinary □ Incontinence □COPD □ □Diabetes □ □Hypertension □ □Osteoarthritis □ □Other: □ Medication List: List all medications you are taking for Parkinson’s and other conditions, including over-the-counter medications and supplements. Medication Dosage Frequency/ Condition Treated Started Timing The National Parkinson Foundation’s Aware In Care campaign aims to help people with Parkinson’s get the best care possible during a hospital stay. For more information please visit www.awareincare.org or call 1.800.4PD.INFO (473-4636).
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