Form Builder
Recent Seizure Follow-up
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
What is the patient's age?
Gender
male
female
prefer not to say
What year was the patient diagnosed with seizures?
was the medical
What type of seizures does/did the patient generally have/had?
Focal Aware Seizures (Simple Partial Seizures)
Focal Impaired Seizures (Complex Partial Seizures)
Absence Seizures - General Onset
Tonic-Clonic Seizures (Grand Mal) - General Onset
Myoclonic Seizures - General Onset
Atonic Seizures - General Onset
Tonic Seizures - General Onset
Clonic Seizures - General Onset
Unknown Seizure Type
Current Seizure Frequency?
Selected Value:
0
Per?
Day
Month
Year
When did the patient's last seizure occur?
Month/Year
The seizures are characterized by?
loss of consciousness
jerking
twitching
repetitive movements
lip smacking
hand clapping
tingling
numbness
visual/auditory hallucinations
sweating
flushing
palpitations
dejavu
fear
emotional outburst
confusion
muscle stiffening
rhythmic jerking
How many minutes do the seizures typically last?
The patient does or does not experience auras prior to seizures?
does
does not
The patient is currently taking?
Keppra(Levetiractam)
Depakote(Valproic Acid)
Tegretol(Carbamazepine)
Lamictal(Lamotrigine)
Trileptal(Oxcarbazepine)
Dilantin(Phenytoin)
Topamax(Topiramate)
Zonegran(Zonisamide)
Klonopin(Clonazepam)
Neurontin(Gabapentin)
Lyrica(Pregabalin)
Other
Dosage and Frequency?
Is the patient's compliance with the medication good, poor, or fair?
good
poor
fair
Medication Side Effects?
drowsiness
fatigue
dizziness
lightheadedness
nausea
vomiting
weight gain
weight loss
ataxia
memory problems
mood changes
skin rash
suicidal thoughts
bone health issues
Relevant medical history?
head trauma
meningitis
encephalitis
stroke
brain tumors
developmental delay
family history
diabetes
heart disease
psychiatric disorders
substance abuse
impaired sleep patterns
stress
significant life changes
considering pregnancy
The patient "is or is not" aware of Georgia driving laws concerning seizures?
is
is not
Submit
NO Recent Seizure Follow-up
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
What is the patient's age?
Gender
male
female
prefer not to say
What year was the patient diagnosed with seizures?
What type of seizures does/did the patient generally have/had?
Focal Aware Seizures (Simple Partial Seizures)
Focal Impaired Seizures (Complex Partial Seizures)
Absence Seizures - General Onset
Tonic-Clonic Seizures (Grand Mal) - General Onset
Myoclonic Seizures - General Onset
Atonic Seizures - General Onset
Tonic Seizures - General Onset
Clonic Seizures - General Onset
Unknown Seizure Type
When did the patient's last seizure occur?
Month/Year
The patient is currently taking?
Keppra(Levetiractam)
Depakote(Valproic Acid)
Tegretol(Carbamazepine)
Lamictal(Lamotrigine)
Trileptal(Oxcarbazepine)
Dilantin(Phenytoin)
Topamax(Topiramate)
Zonegran(Zonisamide)
Klonopin(Clonazepam)
Neurontin(Gabapentin)
Lyrica(Pregabalin)
Other
Dosage and Frequency?
is driving did
Is the patient's compliance with the medication good, poor, or fair?
good
poor
fair
Medication Side Effects?
drowsiness
fatigue
dizziness
lightheadedness
nausea
vomiting
weight gain
weight loss
ataxia
memory problems
mood changes
skin rash
suicidal thoughts
bone health issues
Relevant medical history?
head trauma
meningitis
encephalitis
stroke
brain tumors
developmental delay
family history
diabetes
heart disease
psychiatric disorders
substance abuse
impaired sleep patterns
stress
significant life changes
considering pregnancy
Quality of Life?
good
fair
poor
excellent
Sleep Quality?
adequate
poor
The patient "is or is not" aware of Georgia driving laws concerning seizures?
is
is not
Submit
Migraine Follow-up
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
What is the patient's age?
Mr./Ms.
Mr.
Ms.
Last Name
Gender?
male
female
prefer not to say
She/he
She
He
Her/His
Her
His
What year was the patient diagnosed with migraines?
Number of Migraines?
Selected Value:
0
Per?
week
month
year
Migraines are currently managed with?
Taken?
as needed
daily
monthly
every other day
Migraines are usually?
unilateral
bilateral
Primarily on the?
right side
left side
both sides
or tried currently
Anatomical location?
temporal
frontal
occipital
parietal
Migraine Characteristics?
throbbing
pulsating
stabbing
crushing
piercing
debilitating
intense
excruciating
unrelenting
Intensity?
mild to moderate
moderate to severe
Lasting?
Time?
minutes
hours
days
Associated symptoms?
nausea
photophobia
phonophobia
dizziness
fainting
blurred vision
visual disturbances
tingling
numbness
fatigue
confusion
slurred speech
muscle weakness
hemiplegia
The patient "does or does not" experience auras?
does
does not
Identified triggers include:
caffeine
alcohol
aged cheese
processed meats
skipping meals
bright lights
loud noise
strong odors
weather changes
stress
anxiety
lack of sleep
depression
hormonal fluctuations
menstruation
physical exertion
neck or shoulder tension
overuse of OTC medications
dehydration
sensory overlaod
Recent ED visit?
The patient has not had a recent visit to the emergency department.
The patient visited the emergency department on *** for uncontrolled migraine.
Previously tried and failed medications?
Submit