Syncope and Seizure Questionnaire
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- Barnard Reed
- 5 years ago
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1 Syncope and Seizure Questionnaire World College of Neurology 2/79 Wheatley Drive Bull Creek WA 6149 T F Copyright All rights reserved.
2 Patient Name: MAIN PROBLEM I am here because of (circle all that apply) Seizure/fit Faint Loss of consciousness Near loss of consciousness My symptoms started on: Since then: How many recurrence? How long per attack? When was the most severe episode? When was the last episode? Describe the most severe episode: Date and time? Where were you? What were you doing? How long have you been doing that activity? Are there warning symptoms? How long did the warning last? How long were you unconscious? What was witnessed of you when you were unconscious? Was there tongue biting, prolonged disorientation (more than 15 minutes), urinary incontinence? Any headaches? Any health issues or change in medications prior to dizziness? The overall trend is a 1) worsening since initial onset 2) improvement 3) no change (Please circle one) Dizzy Questionnaire Copyright All rights reserved. 2
3 Provoking factors: (Circle all that apply) Sitting/standing up Turning head Breath holding Coughing Blowing nose Straining Not eating Medication Heat Hot showers Time of day Stress Alcohol Menstrual period (if relevant) During exercise After exercise Certain situations Caffeine Flashing lights Lack of sleep Which is the MAIN provoking factor? Are there any other STRONG provoking factors? Do you have: (Circle all that apply) Hallucinations? Recurrent numbness or jerking movements? Strange rising/falling abdominal sensation or nausea? Déjà vu, fear or altered emotions? Unresponsive blank stares? Sudden 1 or 2 limb jerks not occurring at night? Unexplained incontinence or tongue biting? RISK FACTORS Premature birth Birth complications Developmental delay Febrile convulsions Meningitis Encephalitis Stroke Head trauma Illicit drug use Alcohol/drug withdrawal Major sleep deprivation List of doctors seen, tests, diagnosis and treatments LIFESTYLE How much alcohol do you drink per week? For smokers and ex-smokers How much do you smoke per day? When did you start? When did you stop? Dizzy Questionnaire Copyright All rights reserved. 3
4 Single or married? What sort of work do you do? Are you in litigation or planning litigation regarding your symptoms? Are you disabled due to your condition? Do you drive? For women, Pregnant or planning pregnancy? On oral contraceptive or hormone replacement? Regular menstrual cycles? Peri-menopausal? If menopausal, age of menopause? SYSTEM REVIEW - PLEASE COMPLETE Constitutional Weight loss Fever Skin problem Trouble sleeping Cardiovascular Anaemia Fainting Heart problems High cholesterol Diabetes High blood pressure Low blood pressure Palpitations (abnormal heart beating) Cancer What type and when? Surgery or radiation? Endocrine Low sugar (hypoglycaemia) Thyroid disorder Psychological Treatment by psychiatrist Depression Unusual amount of stress Pain Arthritis Back of jaw (TMJ) Migraine Sinus headaches Tension headaches Low back pain Neck pain Immunological Lupus or other autoimmune disease Breathing problem Asthma COPD/emphysema Pneumonia Sinusitis Deviated septum Stomach problems Ulcer Reflux Constipation Diarrhoea Eye problems (other than glasses) Crossed eyes/lazy eye Poor vision in one eye Cataract Macular degeneration Double vision Neurological B12 deficiency Carpal tunnel Memory loss Meningitis Multiple Sclerosis Pins and needles/numbness (where?) Weakness (where?) Seizures Speech disturbance Tremor/incoordination Renal/Genitourinary Bladder problem Sexual function problem Kidney problem Surgery Breast Cataract Carotid Hysterectomy Ovaries C-section Prostate Appendix Gallbladder Tonsil Epidural Stomach Ear or sinus Other Dizzy Questionnaire Copyright All rights reserved. 4
5 MEDICATIONS (Name, dose, frequency and start date) OTHER TREATMENTS TRIED Medications Indicate helpful or not Physical therapy Yes / No Chiropractic therapy Yes / No Acupuncture Yes / No Alternative therapy Yes / No ALLERGIES Drugs/medication/other? Please indicate reactions FAMILY HISTORY Arrhythmia/pacemaker Sudden cardiac death Heart disease Seizures/Epilepsy Other diseases that run in family? Ethnicity (some diseases are more common in certain ethnic groups) Dizzy Questionnaire Copyright All rights reserved. 5
6 PAST INVESTIGATIONS (Circle and provide copy of report) NEUROLOGICAL TEST 1) Carotid Doppler (ultrasound of the neck arteries) 2) EEG (brain wave test for seizure) 3) MRI or CT Brain 4) MRI or CT Neck BLOOD TESTS List HEART TESTS 1) ECG 2) ECHO 3) Stress test 4) Nuclear heart test 5) Holter 6) Event monitor 7) Implanted recorder 8) Coronary angiogram OTHER IMPORTANT TESTS: Dizzy Questionnaire Copyright All rights reserved. 6
7 Thank you for completing the questionnaire Dizzy Questionnaire Copyright All rights reserved. 7
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Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE New Knee Patient Intake Questionnaire PLEASE PRINT Please provide your referring physician s name, address (if known, if not list the city) and
HEALTH HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synergyspineinjury.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden