Free Seizure Risk Screening

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Disclaimer of Medical Advice:

You understand and acknowledge that all users of this website are responsible for their own medical care, treatment, and oversight. All of the content provided on the website, including text, treatments, dosages, outcomes, charts, profiles, graphics, photographs, images, advice, messages, and forum postings, are for informational purposes only and DOES NOT CONSTITUTE THE PROVIDING OF MEDICAL ADVICE and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or treatment.

The content is not intended to establish a standard of care to be followed by a user of the website. You understand and acknowledge that you should always seek the advice of your physician or other qualified health provider with any questions or concerns you may have regarding your health. You also understand and acknowledge that you should never disregard or delay seeking medical advice relating to treatment or standard of care because of information contained in or transmitted through the website.

Medical information changes constantly. Therefore the information on this webiste or on the linked websites should not be considered current, complete or exhaustive, nor should you rely on such information to recommend a course of treatment for you or any other individual. Reliance on any information provided on this website or any linked websites is solely at your own risk. Completing this questionaire does not establish a patient physician relationship and that this is a tool for the patient and any referring physician to determine how appropriate the service is for them.
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Current Treating PhysicianPlease include your full physician name and telephone number. Will send a copy of the report to your listed physician.
Physician Full Name
Physician Phone #
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Full Name* This field is required.Please include your full name
First Name
Last Name
4
Date of Birth* This field is required.Please include your date of birth
Date
Year
Month
Day
5
Address* This field is required.Please include your mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
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Sudan
Suriname
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eSwatini
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Tonga
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Tristan da Cunha
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Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.please include your email address
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
8
What is your current medical insurance provider?* This field is required.Please select your medical insurance provider below.
Please Select
Please Select
Aetna
BCBS
Cigna
Humana
United Healthcare
Memorial Hermann
Medicare
Medicaid
Self Insured
Other
Select your insurance provider
Not Listed
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Have you ever experienced Confusion or Unsteadiness* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Confused or Unsteady?
Confused or Unsteady?
Yes
No
Sensation of feeling not right; confused or unsteady?
How Often?
How Often?
Daily
Weekly
Monthly
Let us know how often it occurs.
10
Have you ever experienced feeling faint?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Feeling Faint
Feeling Faint
Yes
No
Spells you would describe as feeling faint or as if you might pass out?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
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Have you ever experienced loss of awareness?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Awareness?
Awareness?
Yes
No
Events where you might feel later awareness?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
12
Have you ever experienced temporary confusion?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Temporary Confusion
Temporary Confusion
Yes
No
Episodes of temporary confusion or brain fog?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
13
Have you ever experienced dizziness?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Dizziness
Dizziness
Yes
No
Dizziness accompanied by loss of awareness or confusion?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
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Have you ever experienced trouble expressing yourself?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Expressing Yourself
Expressing Yourself
Yes
No
Difficulty finding the right words or expressing yourself?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
15
Have you ever experienced zoning out or staring blankly?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Zoning Out?
Zoning Out?
Yes
No
Lapse of time or zoning out?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
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Have you ever experienced difficulty recalling?* This field is required.If yes, please describe how often. Daily, Weekly or Monthly.
Difficulty Recalling
Difficulty Recalling
Yes
No
Difficulty recalling the details of conversations you just had or TV shows you just watched?
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
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Have you ever experienced Migraines?* This field is required.Are you experiencing migraines associated with the following symptoms?
Aura
Aura
With Aura
Without Aura
Aura or flashing/shimmering lights, zigzagging time, or stars
How Often?
How Often?
Never
Daily
Weekly
Monthly
Let us know how often it occurs.
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TBI (Traumatic Brain Injury)* This field is required.Have you experienced or experiencing?
YESNO
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TIA (Transient Ischemic Attack/Mini-Stroke)* This field is required.Have you experienced or experiencing?
YESNO
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Brain concussion or Post-concussion syndrome * This field is required.Have you experienced or experiencing?
YESNO
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Dementia * This field is required.Have you experienced or experiencing?
YESNO
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Stroke* This field is required.Have you experienced or experiencing?
YESNO
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Brain Injury, Surgery, or Tumors * This field is required.Have you experienced or experiencing?
YESNO
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Have you had seizures previously? Please list a description of your events during these expereineces.
Huge
Large
Normal
Small
Ok
Ok
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Have you had an EEG before?Please indicate if you have had a procedure before.
Have you had an EEG?
Have you had an EEG?
Yes
No
Let us know!
Results Indicated
Results Indicated
Abnormal
Normal
Unknown
Results of EEG
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Have you had an MRI before?Please indicate if you have had a procedure before.
Have you had and MRI?
Have you had and MRI?
Yes
No
Let us know!
Results Indicated
Results Indicated
Abnormal
Normal
Unknown
Results of EEG
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Patient Signature* This field is required.Finalize the form with your signature
Clear
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