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Requested
Illustration:
1.
DATE MULTIPLE SCLEROSIS WAS DIAGNOSED
2.
IS MULTIPLE SCLEROSIS ACTIVE?
IF
YES,
WHAT IS THE DATE OF THE LAST
ATTACK?
3. WHAT IS THE DEGREE OF SEVERITY OF MULTIPLE SCLEROSIS?
MILD - TOTAL 2 TO 4, MILD EXACERBATION WITH NO RESIDUALS
MODERATE - SLOWLY PROGRESSIVE, 1 OR 2 ATTACKS PER YEAR WITH RECOVERY
BETWEEN ATTACKS, SOME MODERATE RESIDUALS, SUCH AS CANE USE
SEVERE - PROGRESSIVE, MORE THAN 2 ATTACKS PER YEAR, WHEEL CHAIR
CONFINEMENT, BEDRIDDEN
RAPIDLY PROGRESSIVE SYMPTOMS
4. CURRENT SYMPTOMS, (CHECK ALL THAT HAVE OCCURRED OVER THE PAST TWO YEARS):
VISUAL DIFFICULTIES
NUMBNESS
WEAKNESS OR FATIGUE
IMPAIRED SWALLOWING
FREQUENT BLADDER INFECTIONS
BOWL CONTROL DIFFICULTIES
USE OF CANE
USE OF WHEEL CHAIR
DIFFICULTY WITH SPEECH
5. DATE OF CLIENT'S LAST VISIT TO A PHYSICIAN:
6. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO
7.
LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC
DIASTOLIC
8. CLIENT'S OCCUPATION
9. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
10. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
11.
PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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