YALE COMPREHENSIVE EPILEPSY CENTER
NEW PATIENT INFORMATION SHEET
Please fill out the following form to help your physician provide the best possible care.
Date of Appointment: ______________
Name: ________________________________Date of Birth: ___________Age: _____Gender: ____
Home Address: ________________________________________________________________________
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Home phone #:________________Work phone#:_______________Cellular phone #:________________
Referring physician (name and specialty): ________________________________Phone: _____________
Address: ______________________________________________________________________________
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Please list all your other current physicians (name, specialty, address, phone):
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Height: _____ Weight: _____
Handedness:  right-handed
 left-handed
 ambidextrous
PAST MEDICAL HISTORY: Do you have or have you had any of the following medical conditions?
yes
no
yes no
High blood pressure
Stroke or TIA
High cholesterol
Alzheimer’s or other memory disorder
Heart disease
Parkinson’s or other movement disorder
Lung disease
Chronic tremor
Kidney disease or other urological disorder
Migraines
Liver disease
Cancer
Gastrointestinal disease
Chronic menstrual disorder
Chronic skin condition
Immunologic disorder
Loss of Hearing
Chronic allergies/hay fever
Recurrent vertigo
Hematological disorder
Visual loss
Tuberculosis
Glaucoma
HIV or AIDS
Diabetes
Encephalitis or meningitis
Thyroid condition
Head trauma w/ loss of consciousness
Depression
Seizure with high fever as a baby or young child
Psychiatric illness other than depression
Attention deficit/hyperactivity disorder (ADHD)
Chronic sleep disorder
Fainting or blackouts
Please list any other chronic medical illnesses, hospitalizations or surgeries, and provide details of above
conditions.
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REVIEW OF SYMPTOMS: Have you had any of the following symptoms in the past month?
yes
no
yes
Memory loss
Weight loss
Trouble concentrating
Weight gain
Loss of consciousness
Persistent fever
Sedation/lethargy/sleepiness
Depression
Abnormal vision
Anxiety
Loss of Hearing
Hallucinations
Ringing in the ears
Insomnia
Dizziness/vertigo
Chest pain
Speech difficulties
Palpitations
Swallowing difficulties
Shortness of breath
Weakness in one part of the body
Persistent cough
Clumsiness
Persistent nausea or vomiting
Tremor/shaking
Persistent diarrhea
Involuntary movements
Persistent constipation
Rash
Abnormal bleeding/bruising
Hair loss
Difficulty urinating
Abnormal menstrual cycle
Incontinence
Joint pains
Sexual difficulties
Frequent headaches
Persistent pain (describe below)
no
Comments/details:
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Please list all of your CURRENT MEDICATIONS, including birth control pills, vitamins, aspirin, other
over-the-counter medications, herbal remedies, etc:
Name of Medication
example: Tegretol
Tablet size (mgs)
# of tablets you take and what time of day
200 mg
Two at 8 am, one at 3 pm, two at 10 pm
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MEDICATION ALLERGIES (name of drug and type of reaction):
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FAMILY HISTORY
A=Alive / D=Deceased
Current Age / Age of Death
Major Illnesses / Cause of Death
Mother____________________________________________________________________________
Father____________________________________________________________________________
Sibling____________________________________________________________________________
Sibling____________________________________________________________________________
Sibling____________________________________________________________________________
Child_____________________________________________________________________________
Child_____________________________________________________________________________
Other____________________________________________________________________________
Other____________________________________________________________________________
List any neurological diseases (epilepsy, stroke, Parkinson’s, multiple sclerosis, Alzheimer’s, etc.), including
seizures, in your family:
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SOCIAL HISTORY:
Are you currently working?
 yes
 no Occupation: ______________________________________
Marital Status:  single  married  widowed  separated/divorced Number of children:_____
Education:
 less than high school grad
 high school grad
 college grad
Do you currently smoke? If yes, how much? ___________ Did you ever smoke? If yes, when quit? ________
Do you currently drink any alcohol? If yes, how much and how often? _______________________________
Do you currently use any recreational or illegal drugs? If yes, which ones? ___________________________
If no, did you ever use recreational or illegal drugs?  yes
Do you exercise?
 yes
 no
Which one(s)? ______________________
 no If yes, what type and how much? ___________________________________
Are you presently driving?  yes  no Do you have a driver’s license?  yes  no
Are you pregnant?
If yes, which state?_____
 yes  no  not sure
When was your last menstrual period? _________
How would you describe your menstrual cycles?  Regular  Irregular  Absent
Please list any complications of prior pregnancies:
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With whom do you live? __________________________________________________
Please provide a description of your seizures. If you have more than one type, please describe them
separately.
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Do you know about the Epilepsy Foundation?  yes
 no
Thank you very much for taking the time to fill out this form. This will help your physician(s) greatly.