Microsoft word - patient acknowledgement front page 5-14-03.doc

Northeast Regional Epilepsy Group

ACKNOWELEDGEMENT OF RECEIPT OF PRIVACY PRACTICES:
After review of the following document, please sign the FRONT AND BACK of
THIS form and return THIS PAGE ONLY to the receptionist.

I, _____________________________________, hereby acknowledge that I have
received and reviewed the “Notice of Health Information Privacy Practices” which
describes the uses and disclosures that can be made of my personal health information for
treatment, payment and routine health care operations.
________________________________________________ __________________
Signature of patient or representative
________________________________________________ Print name of signer ________________________________________________ If representative, specify relationship ***Please fill out FRONT & BACK of this page*** Thank you Please complete the following information to the best of your knowledge (we will ask
you more details during your office visit):
Date: _____________________
Person filling out this form: ____________________________
Patient Name: ___________________________
Home Telephone: ________________________
Work Telephone: ________________________
Address: ___________________________
_______________________________________
_______________________________________
e-mail address: ___________________________
Date of Birth: ____________________________
Name and address of referring physician:
________________________________________
________________________________________
Telephone: _______________________________
Specialty of referring physician: ____________________
Personal information:
Age: ______________
Gender: ___________
Are you (circle one):

Right-handed
Left-handed
Ambidextrous (use both hands)
Do not know
WHAT IS THE MAIN REASON FOR YOUR VISIT (circle all that apply)?
TO FIND OUT IF YOU HAVE SEIZURES / EPILEPSY? TO BE TREATED FOR SEIZURES TO BETTER CONTROL SEIZURES TO BE EVALUATED FOR SURGERY OTHER (PLEASE DESCRIBE) Please describe your episode(s)/seizures. Please let us know: When did they start (age): • Only one seizure over lifetime • Frequency per day:_______________ • Frequency per month:_____________ • Frequency per year:______________ What is the longest seizure-free interval? Are there any other conditions that tend to bring on seizures (i.e. alcohol, lack of sleep,
new medication, stress or anything else)?
When did you experience your last episode?
Do you feel your episode/seizure coming on (Do you have aura)?
How long does your episode/seizure last?
How do you feel after the episode/seizure ends?
Past Medical History:
Were there any difficulties when your mother was pregnant with you?
YES NO
Was your birth full-term?
YES NO
Were there any difficulties during the labor and/or delivery?
YES NO
Were there any problems in your language development (did you talk on time i.e. prior to
age 15 months)?
YES NO
Were there any problems with your motor skills development (did you walk on time i.e.
prior to age 18 months)?
YES NO
Did you have convulsions associated with fever?
YES NO
Did you have brain infections (meningitis/encephalitis)?
YES NO
Did you have head trauma?
YES NO
If yes did you lose consciousness? YES NO Please mark any medical problems that you have had ________________________________________________________________________ Allergies: _______________________________________________________________ Please list medications that you have experienced an allergic reaction to. _______________________________________________________________________ Please list the current medications (including doses and time of the day you are taking medications). Are you currently or have you ever used following medications? If yes, please state the dosage and number of time(s) per day medication is taken. If you have stopped taking the medication, please give the reason for stopping (such as allergic reaction, side effects, medication not effective). Carbamazepine (Tegretol) Oxcarbazepine (Trileptal) Valproate (Depakote) Phenytoin (Dilantin) Phenobarbital Primidone (Mysoline) Ethosuximide (Zarontin) Benzodiazepines (Ativan, Klonopin, Valium, Diastat, Frisium) Gabapentin (Neurontin) Lamotrigine (Lamictal) Levetiracetam (Keppra) Pregabalin (Lyrica) Topiramate (Topamax) Tiagabine (Gabatril) Felbamate (Felbatol) Vigabatrin (Sabril) Zonisamide (zonegran) ACTH/steroids Acetazolamide (Diamox) Do you/or did you have vagal nerve stimulator implanted? YES NO Have you ever been on ketogenic diet? YES NO PSYCHOSOCIAL:

Do you experience any problems with memory and thinking?
If yes, please tell us when approximately they have started? If yes, please describe
Please specify your highest level of education:
Please specify your current and past occupation:
Do you currently drive?
YES NO
Are you pregnant or planning pregnancy in the near future?
YES NO
FAMILY HISTORY:
Does anybody in your family have/had epilepsy? YES NO
Does anybody in your family have neurological disorders? YES NO PRIOR DIAGNOSTIC WORK UP Please let us know if you had any of following tests in past: EEG: YES NO Was it Routine, Ambulatory or video EEG (circle all that apply) Date it/they was/were done: Institution where it was done: Results: Normal If abnormal, please describe abnormality Head CT Date it was done: Institution: Results: Normal If abnormal, please describe abnormality MRI brain Date it was done: Institution: Results: Normal If abnormal, please describe abnormality If abnormal, please describe abnormality Do you have any specific questions or concerns that you would like us to address during your visit? Is there anything that has not been asked in this questionnaire that you believe is important for your doctor to know? Please explain Signature: ____________________________________

Source: http://epilepsygroup.com/images/files/Patient+Packet+Info.pdf