Clinic Intake Form

Neurosciences Institute - Epilepsy Clinic
NEW PATIENT PERSONAL HISTORY

Confidential Record: Information contained here will not be released unless patient authorizes us to do so.

MRN: Today’s Date:

Last Name: First Name: Middle:

Birth Date: AGE: Sex: (Circle) M F

Address:

City: State: Zip:

Home Phone: Cell Phone: Email:

Notify in case of Emergency (Name): Relationship:

Emergency Contact’s Address: Phone:

Employer: Business Phone:

Referring Physician: Prior Neurologist(s):

My Goals for this visit are:

DO YOU HAVE ANY QUESTIONS FOR THE DOCTOR TODAY?

Please list below:

1.

2.

3.

SEIZURE HISTORY:

1. At what age did you have your very first seizure(s)? year(s) old.

2. Describe the very first seizure you had and what caused it, if known.

3. Please describe your current seizure activity and how often these events occur.

4. How do you feel after seizures (tired, confused, back to normal, etc.) and how long do symptoms last?

Do you ever wake up in the morning with a sore tongue? Yes No

Do you ever wake up with urinary incontinence? Yes No

Do you have any Aura’s or any feelings that you are going to have a seizure? Yes No

Please explain:

RISK FACTORS:

1. BIRTH HISTORY:

a. How were you born? (CIRCLE ONE)

Normal vaginal Vaginal delivery w/ forceps C-section

b. Any complications after birth? Yes No

c. Any seizures immediately after birth? Yes No

d. Difficulty breathing or latching? Yes No

e. Jaundice after birth? Yes No

2. Do you have any history of:

Cerebral palsy Yes

Meningitis or encephalitis Yes

Febrile seizures (fever related) Yes

Staring spells / lost time Yes

Head trauma Yes

Epileptic seizures Yes

Spells Yes

h. Other

HANDEDNESS:

ALLERGIES:

Are you allergic to any medications? Yes No

If yes, please list all medications and the reactions you have had to them:

CURRENT MEDICATIONS:

What medications are you taking? Please name them all, including epilepsy medications and supplements.

PAST ANTI EPILEPTIC DRUGS (AEDs):

Name ALL epilepsy medications have you tried in the past, not including current ones? Please indicate the reason for discontinuation, blood levels or highest dosage tried (if you can remember).

PAST MEDICAL HISTORY:

Have you had or do you have any of the following conditions?

OTHER PAST MEDICAL HISTORY:

SURGERIES: (List procedure and indicate approximate year)

SEIZURE WORK UP:

Have you had any MRIs, CT scans, EEGs, VEEGs, PETs, Craniotomy Workup and/or Tests? If yes, list where and when these were done.

FAMILY HISTORY:

Do any of your blood relatives currently have, or have had in the past, any of the following? Enter the relationship as well:

PERSONAL HABITS:

Do you drink alcohol? Yes No

If yes: Regularly Socially

Hard liquor 1-3 oz per day over 3oz per day

Beer 1 bottle/can per day 2 bottles / cans per day 3 or more

Have you ever been a heavy drinker? Yes No

Do you smoke? Yes No

Have you smoked in the past? Yes No

Do you or have you used recreational / illicit drugs? Yes No

If yes, what have you used?

When did you last use?

Do you drink caffeinated drinks? Yes No

If yes, how much per day?

SOCIAL HISTORY:

Do you have a good social support system (i.e. Family, friends, Church)? Yes No

Have you ever been treated for a drinking or drug problem? Yes No

Do you exercise? Yes No

If yes, how often do you exercise?

Are you active in political, community, hobbies, or church activities? Yes No

What do you do for fun?

VOCATIONAL / EDUCATIONAL / OCCUPATIONAL:

Highest grade completed?

Did you have trouble in school? Yes No

Did you need resource classes? Yes No

Are you currently going to school? Yes No

Are you presently employed? Yes No

What type of work?

How long since you last worked?

Are you on disability? Yes No

MARITAL / FAMILY:

Marital Status: (Circle) Married Single Widowed Divorced

Do you have children? Yes No

If yes, how many what are their ages?

Have you been married more than one time? Yes No

Are there any problems with your married life? Yes No

Do you have any problems with sex? (lack of desire, etc.) Yes No

Is home a safe place for you? Yes No

Do you have any serious problems with your children? Yes No

Is your present home life causing you unhappiness? Yes No

Have there been any deaths in your family or among close friends in the past year or two? Yes No

Does anyone in your family have a drug or alcohol problem? Yes No

Does anyone in your family have a serious illness or disability? Yes No

Have you ever been a victim of abuse… (physical, sexual, or emotional)? Yes No

Are you currently in an abusive situation? Yes No

DRIVING:

Do you drive? Yes No

Have you ever had an accident due to a seizure? Yes No

Are you afraid to drive? Yes No

If you do not drive now, why not?