The seizure episode happened [text] before this evaluation.
Onset while [text].
Episode location: [text]
[select value="no|YES"] <-- Recurrence?
Number of recurrences: [text]
Longest recurrence duration: [text]
The last similar episode was [text]
[select value="the episode|after the episode|neither the episode or after the episode"] <-- The patient remembers
Preceding symptoms
[select value="no|YES"] <-- lightheadedness
[select value="no|YES"] <-- palpitations
[select value="no|YES"] <-- chest pain
[select value="no|YES"] <-- nausea or vomiting
[select value="no|YES"] <-- headache
[select value="no|YES"] <-- abdominal pain
[select value="no|YES"] <-- visual changes
[select value="a moment|a few minutes|more than a few minutes|an hour|hours|days"] <-- Preceding symptoms lasted
Witnessed by [text]
What was witnessed?
[select value="no|YES"] <-- complete loss of consciousness [text]
[select value="no|YES"] <-- confusion following the episode
[select value="no|YES"] <-- urine incontinence
[select value="no|YES"] <-- stool incontinence
[select value="no|YES"] <-- apnea
[select value="no|YES"] <-- pulselessness
[select value="no|YES"] <-- low blood sugar
[select value="no|YES"] <-- extremity weakness
Past Medical History
[select value="no|YES"] <-- Recent trauma [text]
[select value="no|YES"] <-- Seizure history [text]
[select value="no|YES"] <-- Diabetes Mellitus history [text]
[select value="no|YES"] <-- Coronary Artery Disease history [text]
[select value="no|YES"] <-- Cerebrovascular Accident history [text]
[select value="no|YES"] <-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV) [text]
[select value="no|YES"] <-- Pregnancy [text]
Exposures
[select value="no|YES"] <-- Low blood sugar [text]
[select value="no|YES"] <-- Last alcohol [text]
[select value="no|YES"] <-- Drug abuse [text]
[select value="no|YES"] <-- Seizure medications [text]
Associated injuries include: [text]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="http://www.fpnotebook.com" memo="website"][/conditional]