Microsoft word - epilepsy new pt info.doc

EPILEPSY PROGRAM
Phone: 616-685-5050 / Toll Free: 877-752-5137 HEALTH HISTORY QUESTIONNAIRE
Date _______________ Patient Name _______________________________________________________ Date of Birth ________ Age ______ Male _____ Female _____  Right or  Left Handed Address _________________________________________________________ Phone Contact Name ____________________________________________________ Address ____________________________________________________________________________________ Referring Doctor Name ____________________________________________ Address ____________________________________________________________________________________ Primary Care Physician Name _______________________________________ Phone Address ____________________________________________________________________________________ What other physicians have you seen for this problem? _______________________________________________ When did this episode begin? ___________________________________________________________________ Describe onset of symptoms: ___________________________________________________________________ ___________________________________________________________________________________________ Last seizure: __________________________________________ Seizure 1: ___________________________________________________________________________________ ___________________________________________________________________________________________ Seizure 2: ___________________________________________________________________________________ ___________________________________________________________________________________________ Last generalized tonic-clonic _____________________________ Longest seizure free interval: ____________ ALLERGIES: Do you have allergies to food,
MEDICATIONS: Please list the medications (with
dosages) you are currently taking, including over-the- nrsgadmn/rm/EpilepsyClinic/General Pt Info/5-23-08 Epilepsy Program Health History Questionnaire Patient Name ________________________________________________ Today's Date _______ DOB _______ Prior Antiepileptics
Vagus Nerve Simulator (VNS): _______________ Where: ________________ Epilepsy Risk Factors: Central Nervous System (CNS) Infection _____________________ Febrile convulsions _____________ Head Trauma (Loss of Consciousness [LOC] Yes ____ No ____)
Psychiatric/Emotional Signs/Symptoms: (check those that apply to you)
Have You Ever Had An:
If yes, where?
If yes, when?
Epilepsy Program Health History Questionnaire Patient Name ________________________________________________ Today's Date _______ DOB _______ SURGICAL HISTORY
MEDICAL HISTORY
FAMILY HISTORY
Do Any Family Members Have:

Social Work History
Marital Status: _____ Married _____ Divorced _____ Single _____ Widowed _____ Separated
Who is your current employer? ______________________________________ How long? _________________
Status: _____ Full Time _____ Part Time _____ Disabled _____ Retired _____ Homemaker
What is your current occupation? _______________________________________________________________
Are you currently working? __________ If yes, how many hours per week? __________
If not currently working, when was last date worked? _______________________________________________
Epilepsy Program Health History Questionnaire Patient Name ________________________________________________ Today's Date _______ DOB _______ Personal Habits
Times Per Day
General Health
Excellent
Review of Systems (Check all that apply.)
General Gastrointestinal
_____ fever / chills
Musculoskeletal
Head / Ears / Nose / Neck / Throat
Neurologic
Respiratory
Psychiatric
Epilepsy Program Health History Questionnaire
Patient Name ________________________________________________ Today's Date _______ DOB _______
Addendum

__________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ New Patient Physical Exam Worksheet
BP _______________ P _______________ R _______________ Patient ____________________________________________
General Examination:
___________________________________________________________________________________________
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Neurological Examination:
___________________________________________________________________________________________
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Medical Decision Making
Physician Signature ____________________________________ Date ____________ Time ____________ Patient Signature ______________________________________ Date ____________ Time ____________ nrsgadmn/rm/EpilepsyClinic/General Pt Info/5-23-08 GR96601-001 (revised 2/09)

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