7# R%R))))) 3 ===== ]]]f  ]D!Emergency Treatment Request and Information: Below, is information to assist you in treating my patient: ________________________________________________________________________________ for this severe Cluster Headache episode. As you know, Cluster Headache Disorder 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 narcotic 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 Headache 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/Migraine http://headaches.about.com 2001, 2002 Teri Robert, About, Inc. headaches.guide@about.com h-)Y 0 P R$$$$$$$$$$ -.jk&'yzlmY 0  P Q R(@$ R R R R=/BD,Emergency Treatment Request and Information:Theresa M. RobertTimes New Roman$Verdana%Times New Roman CE&Times New Roman Cyr(Times New Roman Greek)Times New Roman Tur*Times New Roman (Hebrew)+Times New Roman (Arabic),Times New Roman Baltic-Times New Roman (Vietnamese) Verdana CE Verdana Cyr Verdana Greek Verdana TurVerdana BalticVerdana (Vietnamese)RR