Epilepsy Institute of North Carolina
The Brain is ...  Where You Live
COMPREHENSIVE EPILEPSY PROGRAM                                           PATIENT CARE • EDUCATION • RESEARCH                                                  BEHAVIORAL HEALTH CENTER                                            THE BRAIN IS WHERE YOU LIVE

PATIENT HISTORY FORM

PATIENT HISTORY

Today's Date:
NAME:: *                       
 ALLERGIES:  
 SMOKING HISTORY:  
 ALCOHOL HISTORY::  
CAFFEINE INTAKE::
RECERATIONAL DRUGS::

FAMILY HISTORY
  HAVE YOU OR ANY BLOOD RELATIVE HAD:
 ALCOHOLISM  SELFRELATIVE
 ASTHMA  SELFRELATIVE
 DEPRESSION
SELFRELATIVE
 DIABETES SELFRELATIVE
 HEART DISEASE
SELFRELATIVE
 LUNG DISEASE
SELFRELATIVE
 STROKE
SELFRELATIVE
 HYPERTENSION SELFRELATIVE
 EPILEPSY SELFRELATIVE
 TRAUMA SELFRELATIVE
 KIDNEY DISEASE
SELFRELATIVE
 LIVER DISEASE
SELFRELATIVE
THYROID DISEASE SELFRELATIVE
 MENTAL ILLNESS
SELFRELATIVE
 HEADACHES/MIGRAINE SELFRELATIVE
 HEADACHES/TENSION SELFRELATIVE
 BLEEDING DISORDER
SELFRELATIVE
 CANCER SELFRELATIVE
 ALLERGY/HAYFEVER SELFRELATIVE
 SLEEP DISORDER
SELFRELATIVE

 
SOCIAL HISTORY:
 

 
   MARRIEDDIVORCEDSINGLEWIDOWED  VET:YESNO
.:PLACE OF BIRTH:
HOW MANY SIBLINGS?:
HOW MANY CHILDREN?:

 
 EDUCATION: GRADE SCHOOLHIGH SCHOOLCOLLEGEPROFESSIONAL SCHOOL


 SURGICAL HISTORY:
 
SURGERIES:
 
 MEDICATIONS CURRENTLY PRESCRIBED
DRUG -- DOSE -- DURATION -- REASON FOR USE -- COMMENTS:
 
  ADVERSE EFFECTS OF MEDICATIONS USED IN THE PAST:
ADVERSE EFFECTS:
 
 VITAMINS AND HERBAL SUPPLEMENTS USED:
 SUPPLEMENTS:  
 
 PREVIOUS MEDICATIONS AND REASONS STOPPED:
PREVIOUS MEDS:

 COMPLIANCE ASSESSMENT:
 HOW OFTEN DO YOU MISS A DOSE OF MEDICATION?:  
ARE YOU HAVING ANY PROBLEMS WITH YOUR MEDICATION REGIMEN?:
ARE MEDICATION COSTS A PROBLEM?:

 EMPLOYMENT:
 EMPLOYER::  
 TYPE OF JOB::  
 ADDITIONAL COMMENTS::