NEW VISIT INFORMATION FORM: Seizures and Related Disorders Please complete the following information: Date:_____________________________________________________________________________________ Name:_____________________________________________________________________________________ Telephone:________________________________________________________________________________ Address:__________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Name and address of referring physician: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Telephone of referring physician: __________________________________________________________________________________________ Please specify what kind of doctor the referring physician is: __________________________________________________________________________________________ Personal information: Age:______________________________________________________________________________________ Gender:___________________________________________________________________________________ Date of Birth:____________________________________________________________________________ Are you right or left-handed?:____________________________________________________________ IN A WORD, WHAT IS THE MAIN REASON FOR BEING REFERRED? ____________________________________________________________________________________________ EPISODE TYPES When did your first episode begin? ____________________________________________________________________________________________ Please list for each different kind of episode type that you have, what happens during the episode. Episode Type#1: Age of onset: ___________. Age it stopped (if applicable): __________ Average frequency per day, month or year: __________________________________________________ Maximum frequency per day, month or year: __________________________________________________ Anything that tends to bring it on (e.g. lack of sleep, alcohol, etc.): ____________________ What are you typically doing it when it comes on? __________________________________________ List step by step, from start to finish the things you notice when experiencing this type of seizure: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ List step by step, from start to finish, what others notice when they see you having a episode: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ How long does the episode typically last: ____________________________________________________________________________________________ What symptoms do you have after the episode finishes: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Independent of the episodes, do you ever experience jerking movements of the arms or legs: __________________________________________________________________________________________ Episode Type#2: Age of onset: _____________________________________________________ age frequency per day, month or year: ____________________________________________________ Maximum frequency per day, month or year: ________________________________________________ Anything that tends to bring it on (e.g. lack of sleep, alcohol, etc.): __________________ What are you typically doing it when it comes on? ________________________________________ List step by step, from start to finish the things you notice when experiencing this type of episode: Age it stopped (if applicable):___________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List step by step, from start to finish, what others notice when they see you having a episode: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How long does the episode typically last:_________________________________________________ What symptoms do you have after the episode finishes:_____________________________________ __________________________________________________________________________________________ Independent of the episodes, do you ever experience jerking movements of the arms or legs: __________________________________________________________________________________________ Episode Type#3: Age of onset:__________Age it stopped (if applicable):_____________ Average frequency per day, month or year:_________________________________________________ Maximum frequency per day, month or year:_________________________________________________ Anything that tends to bring it on (e.g. lack of sleep, alcohol, etc.):___________________ What are you typically doing it when it comes on?_________________________________________ List step by step, from start to finish the things you notice when experiencing this type of episode: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List step by step, from start to finish, what others notice when they see you having an episode: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How long does the episode typically last:_________________________________________________ What symptoms do you have after the episode finishes:_____________________________________ __________________________________________________________________________________________ Independent of the episodes, do you ever experience jerking movements of the arms or legs: __________________________________________________________________________________________ Did you experience dizziness and/or lack of balance? If so, complete the following: Circle the symptoms that best describe your dizziness: (spinning, drunk, motion sickness, lightheaded, floating, feeling giddy, feeling like you left your body, fogginess, cloudiness, other):___________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Was there spinning? Did the world around you seem to spin? Did your head seem to spin more than the world around you?_____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ If the room around you was spinning, what direction did it move?:_________________________ Did you feel off-balance? Did this occur even at times when the dizziness was not present?: __________________________________________________________________________________________ __________________________________________________________________________________________ Related Questions Any history of similar episodes in the past, specify:_____________________________________ If so, how often do episodes occur?:______________________________________________________ Have you been diagnosed with a vestibular disorder?_______________________________________ Did you experience palpitations?__________________________________________________________ Did it get worse with any particular positions of the head or body?:______________________ Was it relieved with any particular positions of the head or body?:_______________________ Any ringing or roaring sounds in the ears, or abnormal sensation of fullness?:____________ __________________________________________________________________________________________ Any particular places in which the episodes occur?________________________________________ Any associated nausea or vomiting?:_______________________________________________________ Any history of hearing loss?:_____________________________________________________________ Have you been treated with antibiotics or other new medications recently?:________________ Does the dizziness remind you of the feeling we all get upon arising from a lying position too quickly?:_________________________________________________________________________________ __________________________________________________________________________________________ Any associated headache, weakness or numbness in a specific part of the body?:____________ Do you have difficulty with coordination in a part of the body?:__________________________ During an episode, do you have loss of consciousness complete or partial?:________________ specify:__________________________________________________________________________________ Anything that brought episodes on?: (ex. Acute bleeding, drinking alcohol or using drugs, head trauma, dialysis, taking a diuretic, poor eating that day, severe sweating, change in blood pressure medication, sudden pain or fear or unpleasant sight, wearing tight-fitting collar, a specific activity, straining, urinating or having a bowel movement, hyperventilating, change in a diabetic medication, etc.)________________________________________________________________ Specify:__________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Past Medical History: Were there any difficulties when your mother was pregnant with you?___________________ __________________________________________________________________________________________ Was your birth full-term?_____________________________________________________________ Were you delivered with the use of forceps or cesarean section?_______________________ __________________________________________________________________________________________ If so, do you know why?___________________________________________________________________ Early Developmental History: As far as you know, were you walking and talking at the normal times?_____________________ __________________________________________________________________________________________ Medical Problems: Do you have a history of any of the following. If so, specify: (Any abnormalities in brain formation, tuberous sclerosis, mental retardation, pimple rash on the face, Sturge-Weber disease, large red blotches on the face or scalp, neurofibromatosis, head trauma, episodes of lack of oxygen, known scarring in the brain, history of seizures at the time of fevers during infancy, episodes occurring during use of any specific medications such as psychological drugs, alcohol abuse, drug abuse, episodes when alcohol or drugs were rapidly stopped, infections such as encephalitis, meningitis, sinusitis, abscess/focal area of infection in the brain, HIV+ or AIDS, toxoplasmosis, tuberculosis, syphilis, lyme disease, tick bites, skin rashes, dementia such as Alzheimer’s disease, high blood pressure, eclampsia, collagen vascular disorders such as lupus, butterfly rash on the face, joint swellings, ulcerations in the mouth or genital area, Sjogren’s disease, dry eyes, dry mouth, any structural lesions in the brain, tumors, multiple sclerosis, vascular abnormalities in the brain, strokes, heart disease such as enlargement of chambers of the hear, irregular heart rhythms, heart valve abnormalities, blood clots, abnormally prolonged Q-T interval on EKG, metabolic abnormalities such as low sodiums, low blood sugars, calcium abnormalities, parathyroid disease, deterioration in thinking functioning or change in behavior, peripheral neuropathy with numbness in the ends of the limbs). ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please list any medical problems that you have had, including dates that these began and what the current status of these problems are. Please include any psychiatric history. Include prior surgeries as well.________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Tobacco: Do you currently use tobacco?____________If so, do you smoke or chew tobacco?_______________ How much do you smoke per day?_______________How long have you been a smoker?_______________ If you do not use tobacco now, but you were a former user, how long ago did you quit?_______ How long did you use tobacco before you quit?_______________________________________________ Alcohol: Do you currently drink alcohol?_____________________________________________________________ How much do you drink in a given day or week?_______________________________________________ Have you ever had a drinking problem?_______________When was your last drink?_______________ Do you have blackouts, seizures, injuries, or other problems due to drinking?_______________ Have you had problems with work or relationships due to drinking?___________________________ Drug Use: Do you use illegal drugs?___________________________________________________________________ If so, what types of drugs, how much, and how often?________________________________________ ____________________________________________________________________________________________ How long have you been using illegal drugs?_________________________________________________ If you do not use illegal drugs currently but did in the past, how long ago did you quit?___ ____________________________________________________________________________________________ How long were you using illegal drugs before you quit?______________________________________ Allergies: Do you have any history of side effects from medications or dyes used for testing?__________ ___________________________________If so, please specify.___________________________________ FAMILY HISTORY Is there any history of neurological disorders in the family? If so, please specify:__ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Family history of seizures?:____________________________________________________________ PRIOR DIAGNOSTIC WORK UP EEG: Please specify the dates and places where an EEG may have been performed in the past and what the results were. Date of EEG#1:____________ Place of EEG:_____________ Type of EEG (routine, 24 hour ambulatory, video-EEG):__________________ Results of EEG:________________________________________________________ Date of EEG#2:____________ Place of EEG:_____________ Type of EEG (routine, 24 hour ambulatory, video-EEG):__________________ Results of EEG: _______________________________________________________ Date of EEG#3:____________ Place of EEG:_____________ Type of EEG (routine, 24 hour ambulatory, video-BEG):__________________ Results of EEG:________________________________________________________ Head CT Scan: Date of CT#1:_____________ Place of CT:______________ Type of CT: (with or without contrast/dye):____________________________ Results of CT__________________________________________________________ Date of CT#2:_____________ Place of CT:______________ Type of CT: (with or without contrast/dye):____________________________ Results of CT._________________________________________________________ MRI of the head: Date ofMRI#1:_____________ Place of MRI:_____________ Type of MRI: (with or without contrast/dye):___________________________ Results of MRI.________________________________________________________ Date of MRI#2:____________ Place of MRI:_____________ Type of MRI: (with or without contrast/dye):___________________________ Results of MRI:________________________________________________________ Date of MRI#3:____________ Place of MRI:____________ Type of MRI: (with or without contrast/dye):___________________________ Results of MRI:________________________________________________________ Neuropsychological Testing Please specify the dates, places, and results of any memory or thinking testing that you may have had.___________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Other Tests: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ TREATMENTS Current Medications: Please specify your current antiepileptic drugs and other medications. Specify the amount of milligrams per pill and how you take the pills per day. Please specify whether you were ever on higher doses, and if so, why the dose was reduced.________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ Name of the medication or other kind of treatment__________________________________________ When did you start?________________________________________________________________________ When did you stop?_________________. Why was it stopped?___________________________________ What side effects did it cause?____________________________________________________________ Was it effective?:_________________________________________________________________________ PSYCHOSOCIAL Please describe any problems you may feel you are having in memory or thinking: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please specify your highest level of education: _________________________________________________________________________________________ Please specify your current and past occupation: _________________________________________________________________________________________ _________________________________________________________________________________________ Please describe your working and past relationships (married, divorced, living with, living in a supervised residence, etc.) _________________________________________________________________________________________ _________________________________________________________________________________________ Please describe any difficulties you are aware of in your mood or quality of life. How much enjoyment do you get from your daily life? Do you feel depressed? _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________