Microsoft word - followup visit form.docx

Form 2. Follow-up Visit Form Patient’s Name: ______________ 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 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)
Other: _______________
Other: _______________
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? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Source: http://www.seizureli.com/pdf/FollowupVisitForm.pdf