Neurology New Patient Seizure History

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Department of Neurology

® New Patient Seizure History

FIRST NAME: LAST NAME:

DATE OF BIRTH: PRIMARY CARE PROVIDER & CLINIC: ®

PREVIOUS NEUROLOGIST:

MY GOALS FOR THIS VISIT ARE:

DO YOU HAVE ANY QUESTIONS FOR THE DOCTOR TODAY?

Please list below:

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.

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3. Please describe your currrent 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?

Yes No

Do you ever wake up in the morning with a sore tongue?

Do you ever wake up in the morning with urinary incontinence?

Do you have any warnings or any feelings that you are going to have a seizure?

Please explain:

HANDEDNESS:

Are you (circle one): Left Handed Right Handed

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a. How were you born? (circle one) Normal vaginal Vaginal delivery w/forceps C-section Yes No

b. Any complications after birth?

c. Any seizures immediately after birth?

d. Difficulty breathing or latching?

e. Jaundice after birth?

2. Do you have any history of:

a. Cerebral palsy

b. Meningitis or encephalitis

c. Febrile seizures (fever related)

d. Staring spells / lost time

e. Head trauma

f. Fainting

g. Other

MEDICATION HISTORY

Please list all MEDICATIONS you take routinely, prescribed or over-the-counter, along with the dosages: (If you are a Portland Clinic patient and our list is up to date leave blank)

Medication: Dose: Frequency:

Please list all allergies and sensitivities (e.g. medications, foods, latex, iodine, etc.)

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

Seizure medication: Reason for discontinuation: Highest dose and/or blood levels:

Here is a quick reference of possible epilepsy medications (can circle if you have taken it):

Acustat Gabitril Pregabalin Activan Keppra Primidone Carbamazepine Klonopin Sodium Valproate Carbatrol Lacosamide Tegretol Celontin Lamictal Tegretol XR Clobazam Lamotrigine Tiagabine Clonazepam Levetiracetam Toprimate Clorazepate Lorazepam Topamax Depakote Lyrica Tranxene Depakote ER Methosuximide Trileptal Diastat Mysoline Valium Diazepam Neurontin Valproic Acid Dilantin Onfi Vimpat Ethosuximide Oxcarbazepine Zarontin Felbamate Phenobarbital Zonegran Frizium Phenytek Zonisamide Gabapentin Phenytoin

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

Yes No Yes No Alcoholism High Blood Pressure Arthritis Headache Asthma Hepatitis Cancer Heart Attack Chest Pain Jaundice Colitis Kidney Disease Depression / Anxiety Other Heart Disease Diabetes Pain (Chronic) Drug Addiction Rheumatic Fever Emphysema Stomach Ulcers Frequent Kidney Infections Thyroid Disease Frequent Bladder Infections Trouble Sleeping Gallbladder disease Suicidal Thoughts Gout Other

SURGERIES: (List procedure and approximate year)

Procedure Year Procedure Year

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

Type of Scan: Where / When:

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:

Yes No Relative(s) Epilepsy or seizure

Migraine

Suicide

Febrile, infantile or childhood seizures

Mental retardation

Kidney stones

Stroke

Cancer (which type)

Brain Tumor

High blood pressure

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Do you drink alcohol? Yes No

If yes: Regularly Socially

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

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

Wine 1-2 glasses per day 3-5 glasses per day more than 5 glasses per day

Do you consume more than 5 drinks within a 24 hour period? Yes No

How many days in the last 6 months did you consume more than 5 drinks in a 24 hour period?

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 above substance?

Do you drink caffeinated drinks? Yes No

If yes, list how many per day of the following: _____ Coffee; _____ Tea; _____ Soda; _____ Energy Drinks

DRIVING:

Do you drive? Yes No

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

Are you afraid to drive? Yes No

If you do not drive now, why not?

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1. Head, Eyes, Ears, Nose, Throat, Lymph Nodes: ——Headaches ——Neck swelling ——Glaucoma ——Double vision ——Pain and/or drainage from ears ——Teethe grinding / clenching ——Hoarseness of voice ——Nasal and/or sinus congestion ——Headaches ——Tinnitus (buzzing or humming) ——Visual loss or change ——Hearing problems ——Photophobia (light bothers eyes) ——Nose bleeds ——Vision problems ——Swollen and/or painful lymph nodes ——Neck stiffness ——Dental problems ——Head trauma ——Sneezing ——Sinus problems ——Deafness ——Sore throat

2. Respiratory System: ——Shortness of breath ——Cough ——Sputum/secretion production ——Hemoptysis ——Wheezing ——Breathing difficulty

3. Cardiovascular System: ——Chest pain, discomfort, heaviness, tightness ——Orthopnea (sleeping on two or more pillows) ——Palpitations ——Shortness of breath with exertion ——Leg swelling ——Chest pain ——PND (waking up short of breath) ——High blood pressure ——Heartburn

4. Gastrointestinal System: ——Anorexia (poor appetite) —— Hematochezia (red blood in bowel movements) ——Dysphagia (difficulty swollowing) ——Nausea and/or vomiting ——Melena (black bowel movements) ——Stomach pain ——Constipation or diarrhea ——Jaundice ——Weight change: loss ____ lbs , gain____lbs ——Weight loss or gain ——Abdominal pain

5. Genitourinary System: ——Hematuria ——Nocturia (urination at night) ——Symptoms of menopause ——Oliguria (infrequent urination) ——Frequency (frequent urination) ——Irregular periods ——Incontinence ——Pyuria (cloudy urine) ——PMS ——Heavy menstrual flow ——Urgency (sensation to urinate) ——Bladder problems ——Polyuria (urination of large volumes of urnie) ——Sexual dysfunction ——Excessive urination or thirst

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Neurology Locations The Portland Clinic - South The Portland Clinic - Downtown THEPORTLANDCLINIC.COM [11009 8/14] 6640 SW Redwood Lane 800 SW 13th Ave Portland, OR 97224 Portland, OR 97205 (503) 620-7358 (503) 221-0161 6. Nervous system: ——Weakness/paralysis one side of body ——Insomnia ——Seizures / shaking ——Urinary and/or fecal incontinence ——Daytime sleepiness ——Numbness (wet or soil underwear) ——Snoring ——Loss of consciousness ——Memory loss, sleep disturbance, —Sleep apnea —Dizziness mood disorders (anxiety, depression) — —

7. Musculoskeletal System: ——Joint pain / swelling / redness ——Neck pain ——Weakness ——Muscle aches and pains ——Leg / foot cramps ——Back pain ——Leg restlessness

8. Dermatological System: ——Rash ——Pruritus (itching) ——Breast lumps / discharge ——Mole changes ——Breast lumps ——Allergic reaction ——Pigmentation (change in color) ——Bleeding or bruising ——Change in skin / hair ——Breast pain ——Changes in nipples

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