Form for the emergency room / from Bennie Sue for liaison - good stuff ..


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Posted by stevevr (65.113.10.68) on May 26, 2001 at 09:23:19:

Emergency Treatment Request and Information:

Below, is information to assist you in treating my patient:

________________________________________________________________________________
for this severe cluster episode. As you know, cluster headache syndrome is a recurrent, episodic neurological disorder. Some episodes can require treatment beyond the medications the patient currently has at home. This patient is neither a substance abuser nor a "drug seeker," but may need emergency medications to treat this episode.

Patient Information: Date of diagnosis: __________________

Current preventive medication(s): _____________________________________________

________________________________________________________________________________

Current abortive and/or pain medication(s): _____________________________________

________________________________________________________________________________

Medications known to be effective for this patient in an emergency situation:

________________________________________________________________________________

________________________________________________________________________________

Thank you for treating my patient. It is often very difficult for cluster patients to receive adequate care offered with dignity and respect because of others who go to emergency departments and after-hours care facilities, feigning symptoms to obtain narcotics. I assure you such is not the case with this patient.

______________________________________________________ _______________________
Signature Date

______________________________________________________ _______________________
Address Office Phone

This form provided by About Headaches/M******* http://headaches.about.com
2001 Teri Robert, About, Inc. headaches.guide@about.com






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