MEDICAL ALERT CARD



MEDICAL ALERT CARD

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).

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 use of restraints.

✓ Administer dopamine-antagonist agents with extreme caution. May exacerbate RLS symptoms.

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 alternatives: Anzemet, Kytril, Zofran

← Anti-psychotics—Haldol, Loxitane, Mellaril, Moban, Navane, Prolixin, Risperdal, Serentil, Stelazine, Thorazine, Vesperin

← Atypical Neuroleptics—approach with caution: Clozaril, Risperdal, Seroquel, Zyprexa; suggested alternative: Abilify

← 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: prtd: 8/05

|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, neurological condition primarily causing extreme discomfort |Address |

|in my legs (sometimes arms & trunk) and creating an irresistible urge |Ph |

|to move. My symptoms increase when at rest or inactive, and typically |Doctor Ph |

|decrease by voluntary movements of my effected 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 use of restraints. | |

|Administer dopamine-antagonist agents with extreme caution. May | |

|exacerbate RLS symptoms. | |

| |Emerg Contact: Ph |

|The following medications (dopamine-antagonist agents) may cause | |

|significant worsening of RLS in some patients. | |

|Administer with EXTREME CAUTION: |PRESCRIPTION medications I take regularly or as needed: |

|Anti-nauseates—Benadryl, Antivert, Atarax, Bonine, Compazine, |Start Date Medication Name & Strength Directions |

|Phenergan, Thorazine, Tigan, Trilaton, Vistaril, Reglan; suggested | |

|alternatives: Anzemet, Kytril, Zofran | |

|Anti-psychotics—Haldol, Loxitane, Mellaril, Moban, Navane, Prolixin, | |

|Risperdal, Serentil, Stelazine, Thorazine, Vesperin | |

|Atypical Neuroleptics—approach with caution: Clozaril, Risperdal, | |

|Seroquel, Zyprexa; suggested alternative: Abilify | |

|Anti-depressants—ALL can cause RLS worsening; possible advantage with | |

|Wellbutrin, trazodone, desipramine, Serzone |NON-PRESCRIPTION medications I take regularly or as needed: |

|Anti-histamines—BEWARE of ALL, especially Benadryl & OTC/Rx combination|Start Date Medication Name & Strength Directions |

|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: prtd: 8/05 | |

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