Patient Information
Name: _________________________
Date: _________________________
Diagnosis: _____________________
Treatment Goals
- Reduce severity and frequency of symptoms
- Improve daily functioning and quality of life
- Maintain independence in activities of daily living
- Minimize medication side effects
Medication Schedule
Current Medications
| Medication |
Dosage |
Frequency |
Purpose |
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Lifestyle Modifications
Exercise Program
- Physical therapy sessions: ____ times per week
- Daily walking: ____ minutes
- Balance exercises: ____ times per day
- Stretching exercises: ____ times per day
Diet and Nutrition
- Maintain regular meal times
- Stay hydrated (_____ glasses of water daily)
- Dietary restrictions: _____________________
Monitoring Plan
Symptoms to Track
- Tremor frequency and severity
- Balance issues
- Rigidity or stiffness
- Sleep patterns
- Medication side effects
Follow-up Schedule
- Neurology appointments: Every _____ months
- Physical therapy: Every _____ weeks
- Blood tests: Every _____ months
Emergency Plan
When to Seek Immediate Care
- Sudden worsening of symptoms
- Severe medication side effects
- Falls with injury
- Difficulty breathing or swallowing
Emergency Contacts
Neurologist: ___________________
Phone: ________________________
Emergency Room: _______________
Support Resources
- Movement Disorder Support Group: _________________
- Physical Therapy Center: ________________________
- Patient Education Materials: _____________________
Notes and Observations
Next Review Date