Form 2. Follow-up Visit Form

Patient's Name: ______________ Date: ______________

Please specify any seizure you had over the past week. Describe step by step, the first thing that happened, the next thing, etc. List what you experienced and then list what others observed. Please also attach your seizure calendar.

Date Description of Seizure

How many seizures occurred over the past month?: ____________________ ;

How many in the preceding month? ________________

How many in the month before that? ________________

When was your last seizure?: _____________________________

List any injuries that occurred as a result of recent seizures? ____________________________________________

Check off the medications you are taking and indicate the total dose per day.

MEDICATION TOTAL DOSE PER DAY (MG/DAY)

Ativan (Lorazepam)

Carbatrol (Carbamazepine)

Depakene/Depakote (Valproic Acid)

Depakote ER (Valproic Acid)

Diamox (Actazolamide)

Dilantin (Phenytoin)

Felbatol (Felbamate)

Gabatril (Tiagabine)

Keppra (Levatiracetam)

Klonopin (Clonazepam)

Lamictal (Lamotrigine)

Mysoline (Primidone)

Neurontin (Gabapentin)

Nitrazepam

Other: _______________
Other: _______________

Other: _______________

Peganone (Ethotoin)

Phenobarbital

Phenytek (Phenytoin)

Sabril (Vigabatrin)

Tegretol (Carbamazepine)

Tegretol X-R (Carbamazepine)

Topamax (Topiramate)

Tranxene (Chlorazepate)

Trileptal (Oxcarbazepine)

Valium (Diazepam)

Zarontin (Ethosuximide)

Zonegran (Zonisamide)

What changes were made in medication doses since the last visit?:

______________________________________________________________________________________

__________________________________________________________________________________

Medications other than antiepileptic drugs. Specify name and total dose per day:

______________________________________________________________________________________

__________________________________________________________________________________

Any herbal, complementary or alternative medicines you are taking. Specify name, and total dose per day.

______________________________________________________________________________________

__________________________________________________________________________________

Approximately when was your last office visit or hospitalization under the supervision of the doctor?

________________________________________________________________________________

What do you believe are the main issues that need to be discussed on today's visit?

________________________________________________________________________________

What labs or X-Rs did you have on or since the last visit that need to be discussed on today's visit? Approximately when were they performed?

________________________________________________________________________________

Do you believe you are experiencing any side effects from your medications/treatments?
If so, please specify:

________________________________________________________________________________

Do you belief you are experiencing any good/positive effects from your treatments?

________________________________________________________________________________