Personal Information
- Name: ________________
- Date of Birth: ________________
- Emergency Contact: ________________
- Phone: ________________
Medical Information
- Primary Neurologist: ________________
- Phone: ________________
- Primary Care Physician: ________________
- Phone: ________________
Type of Neuropathy
□ Diabetic Peripheral Neuropathy
□ Chemotherapy-Induced Neuropathy
□ Other: ________________
Current Medications
-
-
-
Emergency Warning Signs
Seek Immediate Medical Attention If:
- Sudden severe pain or burning sensation
- New weakness or paralysis
- Difficulty breathing
- Severe dizziness
- Injuries due to falls or burns you can't feel
- Signs of infection in numb areas
Emergency Steps
-
For Severe Pain
- Take prescribed rescue medication
- Apply cold/heat as directed by physician
- Contact healthcare provider if pain persists
-
For Injuries
- Check numb areas for wounds daily
- Clean any wounds immediately
- Seek medical attention for deep cuts or burns
-
For Balance Problems
- Sit or lie down immediately
- Use assistive devices if available
- Call for help if needed
Important Notes
- Keep this plan accessible
- Update medication list regularly
- Wear medical alert bracelet if prescribed
- Keep emergency numbers programmed in phone
Emergency Contacts
- Emergency Services: 911
- Neurologist: ________________
- Family Member: ________________
- Pharmacy: ________________