MEDICAL ALERT CARD
MEDICAL ALERT CARD
I, _____________________________, have Restless Legs Syndrome (“RLS”), a chronic 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 affected limb(s).
ATTENTION: Healthcare Providers
✓ Be alert for symptoms described above.
✓ Continue patient’s treatment of choice or administer RLS medications prescribed by patient’s physician to control symptoms.
✓ Avoid restraints.
✓ Administer dopamine-antagonist agents with extreme caution. May exacerbate symptoms of RLS.
The following medications (dopamine-antagonist agents) may cause significant worsening of RLS in some patients.
Administer with EXTREME CAUTION:
← Anti-nauseates--Benadryl, Antivert, Atarax, Bonine, Compazine, Phenergan, Thorazine, Tigan, Trilaton, Vistaril, Reglan; suggested alternative: Kytril, Zofran
← Anti-psychotics--Haldol, Loxitane, Mellaril, Moban, Navane, Prolixin, Risperdal, Serentil, Stelazine, Thorazine, Vesperin
← Atypical Neuroleptics—approach with caution: Clozaril, Risperdal, Seroquel, Zyprexa
← Anti-depressants—ALL can cause RLS worsening; possible advantage with Remeron, Serzone & Wellbutrin
← 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
So Cal RLS Grp: prtd: 9/02
|MEDICATION RECORD
Name
Address
Ph
Doctor Ph
Pharmacist Ph
I am being treated for:
1. 2.
3. 4.
Medication Allergy/Sensitivity Reaction Date
Emerg Contact: Ph
PRESCRIPTION medications I take regularly or as needed:
Start Date 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”), |Name |
|a chronic condition primarily causing extreme discomfort in my legs |Address |
|(sometimes arms & trunk) and creating an irresistible urge to move. My|Ph |
|symptoms increase when at rest or inactive, and typically decrease by |Doctor Ph |
|voluntary movements of my affected limb(s). |Pharmacist Ph |
|ATTENTION: Healthcare Providers |I am being treated for: |
|Be alert for symptoms described above. |1. 2. |
|Continue patient’s treatment of choice or administer RLS medications |3. 4. |
|prescribed by patient’s physician to control symptoms. |Medication Allergy/Sensitivity Reaction Date |
|Avoid restraints. | |
|Administer dopamine-antagonist agents with extreme caution. May | |
|exacerbate symptoms of RLS. | |
| |Emerg Contact: Ph |
| | |
|The following medications (dopamine-antagonist agents) may cause | |
|significant worsening of RLS in some patients. |PRESCRIPTION medications I take regularly or as needed: |
|Administer with EXTREME CAUTION: |Start Date Medication Name & Strength Directions |
|Anti-nauseates--Benadryl, Antivert, Atarax, Bonine, Compazine, | |
|Phenergan, Thorazine, Tigan, Trilaton, Vistaril, Reglan; suggested | |
|alternative: Kytril, Zofran | |
|Anti-psychotics--Haldol, Loxitane, Mellaril, Moban, Navane, Prolixin, | |
|Risperdal, Serentil, Stelazine, Thorazine, Vesperin | |
|Atypical Neuroleptics—approach with caution: Clozaril, Risperdal, | |
|Seroquel, Zyprexa | |
|Anti-depressants—ALL can cause RLS worsening; possible advantage with |NON-PRESCRIPTION medications I take regularly or as needed: |
|Remeron, Serzone & Wellbutrin |Start Date Medication Name & Strength Directions |
|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 | |
| | |
|So Cal RLS Grp: prtd: 9/02 | |
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