Medical Safety Information and Forms for Persons with Parkinson’s and their Care Partners

A complete packet of forms you can download, fill out, print, and have ready to bring with you in the event of any hospital visit.

[Note: Download the blank forms using the link below then fill out and print the forms. None of the information you enter is saved on the PASD website.]

Receipt of medical services, for any reason, has the potential to negatively impact a person with Parkinson’s. Changes to your medication schedule may occur and result in complications that could lengthen your recovery, stay in the hospital, or necessitate follow up care in a nursing facility.

PASD has developed these forms that you can fill out online or download, then print. The forms should be completed with your Movement Disorder Specialist/Neurologist. These forms include a:

1. Physician Letter – to be completed and signed by your Neurologist. The Physician Letter provides information on PD and emphasizes:
   • The need for compliance with medication dosing times and formulations according to your home regimen.
   •  That PD medications must be taken within 15 minutes of the at-home schedule. There is information regarding contraindicated medications and appropriate, safe substitutions.
   •  Recommendations for physical activity, swallow screening, a review of potential complications related to constipation, pneumonia/infection, and the use of NG tubes (often necessary after surgery).
2. Deep Brain Stimulation Form (if applicable).
3. Duopa Form – with details related to Carbidopa/Levodopa Enteral Suspension (if applicable).
4. Special Consideration Regarding Rytary Form – to be completed with and signed by your Neurologist (if applicable).
5. Medication List
6. Personal Contact List
7. Medical Contacts

Next Steps:

1. Review and complete, with the clinician who provides your Parkinson’s care, the:
   • Physician Letter: have him/her sign, date, add phone number and email.
   • DBS and/or Duopa Forms (if applicable).
   • Special Considerations Regarding Rytary Form: have him/her sign and add phone number (if applicable).
2. Review and complete the:
   • Medication List: note name of medication, dose, time of dosing, and any notes.
   • Personal Contacts List.
3. Make copies of all forms and assemble into several sets.
4. Create a “To-Go Kit” containing:
   • Sets of forms – share a set at Pre-Op appts, on admission to the ED, and on a hospital floor
   • Eye mask and ear plugs
   • Complete set of medications in their original RX bottles
   • Phone charger
   • Advanced Healthcare Directive and/or POLST
   • Bottle of water
5.  Place your To-Go Kit near your front door for emergency visits and place an extra set of forms on your refrigerator and in your vehicle(s).

Remember!
You are an important part of the medical team. Share with staff a set of completed forms,
and that you, or the person you care for, has Parkinson’s.