Questionnaire for Periodic Paralysis and Paramyotonia Congenita
Name:
/Date of Birth:
/ Date Completed:1. Do you have attacks of weakness or paralysis? / Yes
/ No
/
Don’t know
1a. If yes, please describe your symptoms:
1b. If no, proceed to question #9.
2. How often do you experience attacks of weakness that completely prevent you from walking?
______per month
3. When you experience one of these attacks, how many hours or days before you are able to walk?
______
4. How many hours or days before you are back to normal? ______
5. How often do you experience attacks that don’t completely prevent you from walking, but interfere with your normal activities?
______per month
6. When you experience one of these attacks, how many hours or days before you are able to continue your normal activities?
______
7. How many hours or days before you are back to normal?
______
8. How often do you experience attacks that you notice, but do not interfere with your daily activities?
______ per month
9. Do you have episodes of muscle stiffness? / Yes
/ No
/
Don’t know
9a. If yes, please describe:
10. Do you have weakness/stiffness in between attacks? / Yes
/ No
/
Don’t know
10a) If yes,what activities can’t you do on account of the weakness/stiffness? Please check all that apply.
Climbing Stairs Combing Hair Lifting HeavyObjects Walking Shampooing Hair Others
Please list others______
11. How old are you currently? ______Years
12. At what age did you have your first symptoms? ______ Years
13. What were your first symptoms?______
14. Is there a particular age at which your symptoms have been the worst? _____ Years
15. Approximately what percent of attacks occur
_____Upon Awakening ______ Other Times in the Morning ______Afternoon ______Evening
16. Does exercise precipitate attacks? / Very Often
/ Sometimes
/ Rarely
/ Never
16a. Ifexercise precipitates attacks, do the attacks come
(Circle One)
During Exercise or After Exercise
16b. If after exercise, how long after exercise do you have an attack?
______
17. Does cold worsen your symptoms? / Yes
/ No
/ Don’t know
18. If yes, describe which symptoms get worse in the cold?
19. Are there any other factors that trigger an episode? Please check all that apply
Stress Sweets Anesthesia
Hunger Heavy Meal Menstruation
(if applicable)
Skipping Meals Alcohol Migraine
Rest Caffeine Other factors
Bananas Pregnancy List other factors______
(if applicable)
20. Are there any other members of your family that experience attacks of weakness and/or stiffness? / Yes
/ No
/ Don’t know
20a. If yes, can you list the members of your family that experience such symptoms?
21. Have you tried any of the following medications? If so, how were your episodes affected?
Please check all that apply: Information about Medications:
Acetazolamide (Diamox)
Dichlorphenamide (Daranide)
Mexilitene
Potassium
Phenytoin (Dilantin)
Gabapentin (Neurontin)
Other Medications
Please list any other medications:
Questions 22-27 pertain to medical care you may or may not have received and tests that may or may not have been performed to evaluate the functioning of your nervous system.
22. Have you ever had your potassium levels tested during an attack? / Yes / No
/ Don’t know
23a. If yes, when and where did you have this done? (give date) ______
(give location) ______
23b. If yes, what was your potassium level?
(Give exact level if known) ______/ High
/ Normal
/ Low
24. Have you ever had an EMG done? / Yes
/ No
/ Don’t know
24a. If yes, when and where did you have this done? (give date) ______
(give location) ______
Please give results if known ______
25. Have you ever had a muscle biopsy? / Yes
/ No
/ Don’t know
25a. If yes, when and where did you have this done? (give date) ______
(give location)______
Please give results if known ______
26. Have you ever had your thyroid tested? / Yes
/ No
/ Don’t know
26a. If yes, when and where did you have this done? (give date) ______
(give location)
Please give results if known ______
27. Any other comments that you would like to include: