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SEIZURE QUESTIONNAIRE
* = required

Patient Name: *
Date of birth: * / /
Primary Phone #: *
Secondary Phone #:
Email Address: *
 
Have you been diagnosed with seizures? Yes
No
 
How long have you had seizures? Less than 1 year
1-4 years
5 or more years
I have only had 1 or 2 seizures
 
How often do you have seizures? Never
1-4 per month
5-10 per month
Multiple seizure every day
Other:  
 
What type of seizures do you have? Primary generalized tonic-clonic
Partial seizures
Absence
Myoclonic
Atonic
I don't know
 
Are you currently being treated
for your seizures? 		Yes
No
 
Are you currently taking any
of the following anti-epileptic
medications? (Check all that apply) 		Phenytoin ( Dilantin)
Carbamazepine (Tegretol, Tegretol-XR, Carbatrol)
Divalproex Sodium (Depakote, Depakote-ER)
Topiramate (Topamax)
Lamotrigine (Lamictal)
Gabapentin (Neurontin)
Oxcarbazepine (Trileptal)
Pregabalin (Lyrica)
Levetiracetam (Keppra)
Phenobarbital
Felbatol (felbamate)
Other:  
 
Do you sometimes have several
different seizures within a
few hours (a flurry of cluster of seizures)?

 Yes
No
Do you have an active vagal nerve
stimulator (VNS)?

Yes
No
Comments:
 
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