MEDICAL ALERT CARD
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MEDICAL ALERT CARD MEDICATION RECORD I, _____________________________, have Restless Legs Syndrome (“RLS”), a chronic, neurological condition primarily causing extreme discomfort in my legs (sometimes arms & trunk) and creating an irresistible urge to move. My symptoms increase when at rest or inactive, and typically decrease by voluntary movements of my effected limb(s). Name _____________________________________________ ATTENTION: Healthcare Providers Continue patient’s treatment of choice or administer RLS medications prescribed by patient’s physician to control symptoms. Avoid use of restraints. extreme Anti-nauseates—Benadryl, Antivert, Atarax, Bonine, Compazine, Phenergan, Thorazine, Tigan, Trilaton, Vistaril, Reglan; suggested alternatives: Anzemet, Kytril, Zofran Moban, Atypical Neuroleptics—approach with caution: Seroquel, Zyprexa; suggested alternative: Abilify 1. _____________________ 3. _____________________ Medication Allergy/Sensitivity ___________________ ___________________ 2. _____________________ 4. _____________________ Reaction Date ___________________ ___________________ _______ _______ Navane, Clozaril, Prolixin, Risperdal, Anti-depressants—ALL can cause RLS worsening; possible advantage with Wellbutrin, trazodone, desipramine, Serzone Anti-histamines—BEWARE of ALL, especially Benadryl & OTC/Rx combination cold/sinus/cough medications: Actifed, Comtrex, Contact, Dimetapp, Triaminic, TheraFlu, Vicks cough syrup, Tylenol PM, Excedrin PM, Bayer PM, Sominex, Unisom; suggested alternatives: Allegra, Alavert, Claritin, Clarinex So Cal RLS Grp: www.rlshelp.org PRESCRIPTION medications I take regularly or as needed: Start Date Administer with EXTREME CAUTION: Loxitane, Mellaril, Risperdal, Serentil, Stelazine, Thorazine, Vesperin Pharmacist _____________________ Ph ______________ Emerg Contact: __________________ Ph _______________ The following medications (dopamine-antagonist agents) may cause significant worsening of RLS in some patients. Anti-psychotics—Haldol, _______________________________ Ph ______________ Doctor _________________________ Ph ______________ I am being treated for: Be alert for symptoms described above. Administer dopamine-antagonist agents with caution. May exacerbate RLS symptoms. Address ___________________________________________ prtd: 8/05 Medication Name & Strength Directions _______ ____________________________ ___________ _______ _______ ____________________________ ____________________________ ___________ ___________ _______ ____________________________ ___________ _______ _______ ____________________________ ____________________________ ___________ ___________ NON-PRESCRIPTION medications I take regularly or as needed: Start Date Medication Name & Strength Directions _______ ____________________________ ___________ _______ ____________________________ ___________ _______ ____________________________ ___________ MEDICAL ALERT CARD MEDICATION RECORD I, _____________________________, have Restless Legs Syndrome (“RLS”), a chronic, neurological condition primarily causing extreme discomfort in my legs (sometimes arms & trunk) and creating an irresistible urge to move. My symptoms increase when at rest or inactive, and typically decrease by voluntary movements of my effected limb(s). Name _____________________________________________ ATTENTION: Healthcare Providers Continue patient’s treatment of choice or administer RLS medications prescribed by patient’s physician to control symptoms. Avoid use of restraints. extreme Anti-nauseates—Benadryl, Antivert, Atarax, Bonine, Compazine, Phenergan, Thorazine, Tigan, Trilaton, Vistaril, Reglan; suggested alternatives: Anzemet, Kytril, Zofran Atypical Moban, Neuroleptics—approach with caution: Seroquel, Zyprexa; suggested alternative: Abilify Navane, Clozaril, Prolixin, Risperdal, Anti-depressants—ALL can cause RLS worsening; possible advantage with Wellbutrin, trazodone, desipramine, Serzone Anti-histamines—BEWARE of ALL, especially Benadryl & OTC/Rx combination cold/sinus/cough medications: Actifed, Comtrex, Contact, Dimetapp, Triaminic, TheraFlu, Vicks cough syrup, Tylenol PM, Excedrin PM, Bayer PM, Sominex, Unisom; suggested alternatives: Allegra, Alavert, Claritin, Clarinex So Cal RLS Grp: www.rlshelp.org 1. _____________________ 2. _____________________ 3. _____________________ 4. _____________________ Medication Allergy/Sensitivity ___________________ ___________________ Reaction Date ___________________ ___________________ _______ _______ PRESCRIPTION medications I take regularly or as needed: Start Date Administer with EXTREME CAUTION: Loxitane, Mellaril, Risperdal, Serentil, Stelazine, Thorazine, Vesperin Pharmacist _____________________ Ph ______________ Emerg Contact: __________________ Ph _______________ The following medications (dopamine-antagonist agents) may cause significant worsening of RLS in some patients. Anti-psychotics—Haldol, _______________________________ Ph ______________ Doctor _________________________ Ph ______________ I am being treated for: Be alert for symptoms described above. Administer dopamine-antagonist agents with caution. May exacerbate RLS symptoms. Address ___________________________________________ prtd: 8/05 Medication Name & Strength Directions _______ ____________________________ ___________ _______ _______ ____________________________ ____________________________ ___________ ___________ _______ ____________________________ ___________ _______ ____________________________ ___________ _______ ____________________________ ___________ NON-PRESCRIPTION medications I take regularly or as needed: Start Date Medication Name & Strength Directions _______ _______ ____________________________ ____________________________ ___________ ___________ _______ ____________________________ ___________
