AHC Form
Today’s Date:
Month: _____ Day: ____ Year: ______
Name of person completing form: First: ____________ Last: ________________
Relationship to Patient:
__ Self
__ Legal Guardian
__ Other:___________________________
----------------------------------------------------------------------------------------------PATIENT INFORMATION
Patient’s Name:
First:________________ Last:___________________
Patient’s Birth Date:
Month: _____ Day: ____ Year: ______
Patient’s Gender:
_____Male
Patient’s Race:
___White
___Black or African American
___Asian
___Hispanic or Latino
___American Indian and Alaska Native
___Other:________________________________
Patient’s Address:
Street______________________________________
_____Female
City: _____________________State/Province: ________
Postal Code: _________ Country:________________
Patient’s Phone:
Home:__________________ Cell: ___________________
Patient’s Primary e-mail:
________________________________
Patient’s Secondary e-mail:
________________________________
------------------------------------------------------------------------------------------------
Page 1 of 27
MOTHER’S INFORMATION
Mother’s Name:
First: ________________ Maiden: _________________
Mother’s Birth Date:
Month: _____ Day: ____ Year: ______
Mother’s Address:
Street_________________________________________
City: _____________________State/Province: ________
Postal Code: _________ Country:________________
Mother’s Home Phone: _____________________________________________
Mother’s Cell Phone:
______________________________________________
Mother’s Work Phone: ______________________________________________
Mother’s Primary e-mail:_____________________________________________
Mother’s Secondary e-mail: ___________________________________________
----------------------------------------------------------------------------------------------FATHER’S INFORMATION
Father’s Name:
First: ________________ Last: ___________________
Father’s Birth Date:
Month: _____ Day: ____ Year: ______
Father’s Address:
Street_________________________________________
City: _____________________State/Province: ________
Postal Code: _________ Country:________________
Father’s Home Phone: _____________________________________________
Father’s Cell Phone:
______________________________________________
Father’s Work Phone:
______________________________________________
Father’s Primary e-mail:_____________________________________________
Father’s Secondary e-mail: ___________________________________________
----------------------------------------------------------------------------------------------Page 2 of 27
LEGAL GUARDIAN’S INFORMATION (If other than parent or patient)
Legal Guardian’s Name: First: ________________ Last: ___________________
Guardian’s Address:
Street______________________________________
City: _____________________State/Province: ________
Postal Code: _________ Country:________________
Guardian’s Home Phone:__________________________________________
Guardian’s Cell Phone: ______________________________________________
Guardian’s Work Phone:______________________________________________
Guardian’s Primary e-mail:____________________________________________
Guardian’s Secondary e-mail: __________________________________________
---------------------------------------------------------------------------------------------DOCTOR’S INFORMATION
Doctor's Name:
First: ________________ Last: ___________________
Doctor’s Specialty: ____________________________________________
Doctor’s Phone:
_____________________________________________
Doctor’s Address: Street_________________________________________
City: _____________________State/Province: ________
Postal Code: _________ Country:________________
----------------------------------------------------------------------------------------------
Page 3 of 27
General health questions to be completed by parent(s) of child with AHC:
1.
How many total children do you have?
2.
What is your child’s current age (child with AHC)? ______years ______months
3.
Does your child have any: (mark all that apply)
a. Skin discolorations
b. Café au lait spots
c. Birthmarks
d. Nevis
4.
Does your child have hip problems? (mark all that apply)
a. No
b. Yes-hip pain
c. Yes-hip displacement
d. Yes-diagnosed hip dysplasia
i. Surgically repaired
ii. Not surgically repaired
iii. PT
iv. No PT
5.
Does your child suffer from constipation?
a. Never
b. Occasionally
c. Frequently
d. Chronically
6.
7.
8.
9.
Does your child display any obsessions or compulsions?
a. Yes
b. No
c. Not sure
If yes, please describe:
What surgical procedures has your child had?
Is your child wheelchair bound?
a. Yes
b. No
If yes, what percent of the time does your child use the wheelchair?
a. 1-10%
b. 11-25%
c. 26-50%
d. 51-75%
e. 76-100%
Other medical problems:
□ Liver Problems (hepatic insufficiency)
□ Heart rhythm abnormalities (cardiac arrhythmia)
□ Kidney Problems (renal insufficiency)
□ Seizure disorder (epilepsy)
□ Congenital heart disease
□ Central nervous system
□ Pancreatic abnormalities
□ Bleeding disorder (coagulopathy)
Page 4 of 27
□ Respiratory system abnormalities
□ Urogenital abnormalities
□ High blood pressure (hypertension)
□ Endocrine abnormalities
□ Gastrointestinal disorder
□ Hearing loss
□ Fatty acid or mitochondrial disorder
□ Immune disorder
□ Urea cycle disorder
□ Other _____________________________________
AHC Questions
1. What type of attacks has your child experienced?
(Please either circle answers, check the correct box, or fill in blanks for questions below)
1a. Color or temperature change :
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
How often does your child currently have color or temperature changes?
a. Multiple times a day
b. Once a day
c. Multiple times a week
d. Once a week
e. Multiple times a month
f. Once a month
g. Multiple times a year
h. Once a year
i. Never
Page 5 of 27
1b. Tonic or dystonic episodes (stiffness, posturing):
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
1c. Hemiplegic episodes, or limpness on one side:
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
1d. Quadriplegic episodes, or limpness on both sides (Full-body episodes):
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
Page 6 of 27
1e. Currently, are your child’s spells predominantly?
Stiffness (posturing, dystonia), or
Floppiness (flaccid paralysis)
_________________________________________________________________________
1f. Breathing difficulties:
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
Has your child actually had a respiratory arrest and stopped breathing entirely?
yes
no
don’t know
If yes, please describe:
How many times has your child been intubated for breathing difficulties? _____
Please describe:
Page 7 of 27
1g. Eye movement abnormalities:
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
Do eye movement abnormalities occur predominantly?
Before episodes
During episodes
After episodes
1h. Seizures or convulsions (episodes associated with loss of consciousness or
altered consciousness):
yes no
don’t know
Age of onset: ____years _____ months _____weeks _____days
Seizure type(s):
Please describe (whole body or one-sided limb shaking, stiffness, eyes rolling, etc.):
Is your child able to communicate during seizures?
Has your child ever had an episode of status epilepticus or persistent seizure activity lasting
for more than 20 minutes?
yes no
don’t know
Has your child had seizure activity documented on EEG?
yes
no
don’t know
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
Page 8 of 27
1i. Tremor (involuntary shaking or trembling movements):
yes
no
don’t know
Age of onset: ____years _____ months _____weeks _____days
In the past year, how long did your child’s:
Longest episode last? ____ days ___hours ___minutes ___seconds
Shortest episode last? ____ days ___hours ___minutes ___seconds
How long does a typical episode last? ____ days ___hours ___minutes ___seconds
2. Does your child experience any ongoing neurologic symptoms between attacks, when
your child is NOT having an episode?
2a. Ataxia, or balance problems If yes, please give details:
yes
no
don’t know
2b. Incoordination, or trouble with precise movements If yes, please give details:
2c. Speech Impediment, slurring, or difficulty with speech If yes, please give details:
yes
yes
no
don’t know
no
don’t know
2d. Cognitive impairment, or trouble with thinking, understanding, attention, or memory
yes
no
don’t know
If yes, please give details:
Page 9 of 27
3. Does sleep have any effect on your child’s episodes?
If yes, please give details.
3a. Does your child routinely have difficulty sleeping?
If yes, please give details:
yes
yes
no
no
don’t know
don’t know
3b. Has your child had abnormal behavior of any type (seizures, sleepwalking, etc) during
sleep?
yes
no
don’t know
If yes, please give details:
4. Has your child had a formal neuropsychological evaluation?
Please give details.
yes
no
don’t know
5. In years, what would you estimate your child’s level of cognitive function to be?
(Please Circle)
6 mos
1 yr
2-3 yrs
4-5 yrs
6-7 yrs
6. Have you noticed a slowing in development
or progressive cognitive impairment?
(Please Circle)
8-9 yrs
10-12
yrs
Other ___
Yes
No
Don’t know
7.
7 In years, what would you estimate your child’s level of gross motor skills to be? (Please
Circle)
6 mos
1 yr
2-3 yrs
4-5 yrs
6-7 yrs
Page 10 of 27
8-9 yrs
10-12
yrs
Other ___
8. Does your child have a predominant side of hemiplegia? (Please Circle)
yes
no
don’t know
8a. If yes, does your child’s hemiplegia always occur on 1 side only?
yes
no
don’t
know
8b. Please give details.
9. Is your child able to communicate by any
means during a hemiplegic episode, when one
side of body is involved?
Yes
No
Don’t know
No
Don’t know
No
Don’t know
9a. If so, please explain (i.e. eye movement, finger, voice, etc)
9b. Is your child able to communicate by any
means during a quadriplegic episode, when
both sides of body is involved in a full-body
episode?
Yes
9c. If so, please explain (i.e. eye movement, finger, voice, etc)
9d. Is your child able to communicate between
episodes, when they are not in an episode?
Page 11 of 27
Yes
9e. If so, please explain (i.e. eye movement, finger, voice, etc)
10. Do any of the following factors below bring on your child’s symptoms?
(Please Circle)
Food
Specific
activities
Swimming
Pool
Sunlight
Stress
Medications
Bathing
Excitement
Fluorescent
lights
Temperature
Menses
Hormonal
changes
10a. If yes, please give details.
11. Have any prescription medications
(including birth control pills), or over-thecounter medications reduced the frequency,
severity, or duration of AHC episodes?
11a. If yes, please provide details:
11b. Have any prescription or over-thecounter medications aggravated the
frequency, severity, or duration of your child’s
AHC episodes?
11c. If yes, please list:
12. Does your child have any mood or
behavioral problems?
12a. If yes, please give details.
Page 12 of 27
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
13. Has your child received medication for
treatment of mood or behavioral problems?
13a. Have any medications been helpful for
management of your child’s mood or
behavioral difficulties? If so, please list:
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Normal
Abnormal
Don’t know
Yes
No
Don’t know
Normal
Abnormal
Don’t know
Yes
No
Don’t know
Normal
Abnormal
Don’t know
14. Has your child had an EEG?
14a. If yes, did any episodes occur during
EEG?
14b. If yes, were results normal or abnormal?
14c. Please list location of EEG testing:
14d. Please list name of physician who requested the EEG:
15. Has your child had a MRI?
15a. If so, was it normal or abnormal?
15b. Please list location of MRI testing:
15c. Please list name of physician who requested the MRI:
16. Has your child had a PET scan?
16a. If so, was it normal or abnormal?
Page 13 of 27
17. Has your child had an angiogram?
Yes
No
Don’t know
Normal
Abnormal
Don’t know
Yes
No
Don’t know
Normal
Abnormal
Don’t know
Yes
No
Don’t know
Normal
Abnormal
Don’t know
19b. Were you told to follow up with
Cardiology?
Yes
No
Don’t know
20. Has your child had a muscle biopsy?
Yes
No
Don’t know
Normal
Abnormal
Don’t know
Yes
No
Don’t know
Normal
Abnormal
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
17a. If so, was it normal or abnormal?
18. Has your child had an MR Spect scan?
18a. If so, was it normal or abnormal?
19. Has your child had an EKG within the last
year?
19a. If so, was it normal or abnormal?
20a. If so, was it normal or abnormal?
21. Has your child had a skin biopsy?
21a. If so, was it normal or abnormal?
22. Has your child experienced numbness or
tingling?
23. Has your child experienced visual loss?
24. Has your child experienced hearing loss?
25. Is there a history of Migraine or other
headaches in your family?
25a. Please specify relationship to patient:
Page 14 of 27
25b. If so, are migraines associated with:
26. Does your child appear to have or
complain of headaches?
26a. If so, do they occur during episodes,
between episodes, or both?
27. Does your child seem to be in pain during
attacks?
28. Are there any immediate family members
with cognitive problems? (Developmental
delay, mental retardation, autism, etc)
Weakness
Numbness
Tingling
Yes
No
Don’t know
During
Between
Both
Yes
No
Don’t know
Yes
No
Don’t know
29. Pregnancy and birth history: Please provide detailed answers to questions below:
a. Any complications during pregnancy?
b. Did Mom take any medications during the pregnancy?
c. Was baby born prematurely or on time?
d. Was delivery vaginal or c-section?
e. If delivery was via c-section, explain circumstances:
f. Any complications during delivery?
Page 15 of 27
g. Birth weight:
h. Apgar scores if available?
Page 16 of 27
30. Developmental history:
a. At what age did your child first gain head control? ___years ___months
b. At what age did your child first sit unsupported? ___years ___months
c. At what age did your child first crawl? ___years ___months
d. At what age did your child first walk using furniture? ___years ___months
e. At what age did your child first walk alone without any help? ___years ___months
f. At what age was your child’s first word? ___years ___months
g. At what age did your child first put two words together? ___years ___months
h. At what age did your child first use sentences? ___years ___months
i. At what age did your child first write his/her name? ___years ___months
j. Does your child currently write?
yes
no
If yes, at what age level? ___years ___months
don’t know
k. At what age did your child first learn to read? ___years ___months
l. Does your child currently read?
yes
no
If yes, at what age level? ___years ___months
Page 17 of 27
don’t know
31. Use the definitions below to answer the following 3 questions about how your
child moves around when he/she is not in an episode:
6
5
4
3
2
1
C
N
Definitions
Independent on all surfaces. Does not use any walking aids or need any help from
another person when walking over all surfaces, including uneven ground, curbs, etc
and in a crowded environment.
Independent on level surfaces. Does not use walking aids or need help from another
person. Requires a rail for stairs. If uses furniture or walls for support, please mark
#4.
Uses a cane (one or two), without help form another person.
Uses crutches without help from another person.
Uses a walker or frame, without help form another person.
Uses wheelchair, may stand for transfers, and may do some stepping supported by
another person or using a walker/frame.
Crawling, child crawls for mobility at home (at least 5 yards)
Does not apply. For example child does not complete the distance (of at least 5, 50,
or 500 yards, depending on the question.
Please circle your answer
31a. How does your child move around for short distances
in the home?
(distances of 5 yards)
31b. How does your child move around and in between
classes at school?
(distances of 50 yards)
31c. How does your child move around for long distances,
such as at the shopping center? (distances of 500 yards)
Page 18 of 27
6 5 4 3 2 1 C N
6 5 4 3 2 1 C N
6 5 4 3 2 1 C N
32. Please fill in how often, on average in the past month, your child used a:
How many days a week
Wheel chair
Stroller
Hand/Arm Braces
Leg Braces
Manual
Power
Not sure which one
Regular
Adaptive
Not sure which one
Resting hand splint
Benik splints
Elbow splints
Not sure which one
SMO’s
AFO’s
KAFO’s
HKAFO’s
Not sure which one
Page 19 of 27
How long each day
33. Can your child?
Unable
to do
any part
of this
task
Able to do a
part of this
task but
requires a
lot of help to
complete it.
Able to do
task but
requires
some
assistance to
complete it
Comb
hair
Brush
teeth
Shower
or bath
Toilet
hygiene
Pick out
clothes
Get
dressed
Button
buttons
Put on
shoes
Tie
shoes
Prepare
cereal or
sandwich
Eat with
spoon
Eat with
fork
Use knife
to cut
Drink
from cup
Draw a
triangle
Write a
sentence
Access
and use
internet
Use cell
Page 20 of 27
Able to task
with only a
little bit of
assistance to
complete it
Able to
complete
entire
task all
on own
Not
applicable or
not age
appropriate
phone
Count
change
Read a
book
34. How often does your child see this health care provider?
Never
Stoppe Once a
d over year
a year
ago
Several
times a
year
Outpatient PT
(physical
therapist)
School PT
(physical
therapist)
Outpatient
OT
(occupational
therapist)
School OT
(occupational
therapist)
Outpatient
SLP or ST
(speech
therapist)
School
SLP or ST
(speech
therapist)
Primary care
provider or
Pediatrician
Emergency
room staff
Child
Neurologist
Pediatric
Physiatrist or
Rehab doctor
Home care
nurse/aide
Page 21 of 27
Once a
month
Several
times a
month
Once a
week
Several
times a
week
35. Does you child attend:
 Preschool
 Kindergarten
 School
 College
 Vocational school
 Other_______________
36. Are the classes:
 Regular
 Special/private
 Resource
 Other_______________
37. Does your child have an IEP (individual education plan)?
 Yes, currently has
 Yes, has in the past but not now,
 No, never had IEP
 Not sure
38. Does your child have a 504 plan?
 Yes, currently has,
 Yes, has in the past but not now,
 No, never had a 504 plan
 Not sure
39. Does your child participate in regular physical exercise (this may include a
home stretching or strengthening program)?
 Yes, currently
 Yes, in the past
 No, never
37a. If yes, please describe:
40. Does your child participate in any sports?
 Yes, currently
 Yes, in the past
 No, never
39a. If yes, please describe:
Page 22 of 27
41. Please list any Herbal Supplements your child is taking:
42. Please list any Vitamin Supplements your child is taking:
43. Please indicate on the following list what medications your child has taken in
the past, and what medications they are currently on:
For table below:
mg=milligrams, g=grams, mL=milliliters, PO=by mouth, IV=injection into vein,
IM=injection into muscle, PR=per rectum, Nas=nasally.
MEDICATIONS
Brand Name
Generic Name
Akineton
Aldex AN
Ambien
Amerge
Biperidin
Aldex AN
Zolpidem
Naratriptan
Naratriptan
hydrochloride
IsomethepteneAcetaminophenDichloralphenazone
Amobarbital
Amytal
Clomipramine
Apomorphine
Chloral hydrate
Trihexyphenidyl
Amerge
Amidrine
Amobarbital
Amytal
Anafranil
Apokyn
Aquachloral
Artane
WHEN
Past
Page 23 of 27
Now
DOSE
(mg, g,
mL)
ROUTE
(PO, IV, IM,
PR, Nas)
FREQUENCY
(times per
day/week)
Atarax
Ativan
Axert
Azilect
Benadryl
Ben-Tann
BuSpar
Butisol
Cafergot
Carbatrol
Celexa
Cerebyx
Cogentin
Concerta
Cymbalta
Dalmane
Depakene
Depakote
Desyrel
DHE 45
Diamox
Dilantin
DiphenMax
Duradrin
Dytan
Dytuss
Effexor
Elavil
Eldepryl
Emsam
Endep
Entacapone
Epitol
Equagesic
Esgic
Eskalith
Felbatol
FentanylDroperidol
Fioricet
Frova
Hydroxyzine HCl
Lorazepam
Almotriptan
Rasagiline
Diphenhydramine
HCl
Diphenhydramine
Buspirone
Butabarbital
Caffeine/ergotamine
Carbamazepine
Citalopram
Fosphenytoin
Benztropine
Methylphenidate
Duloxetine
Flurazepam
Valproic acid
Divalproex sodium
Trazodone
Dihydroergotamine
Acetazolamide
Phenytoin
Diphenhydramine
Tannate
IsomethepteneAcetaminophenDichloralphenazone
Diphenhydramine
Tannate
Diphenhydramine
Tannate
Venlafaxine
Amitryptiline
Selegiline
Selegiline
Amitryptiline
comtan
diphenhydramine
Cabamazepine
Meprobamate
AcetaminophenCaffeine-Butalbital
Lithium Carbonate
Felbamate
Fentanyl-Droperidol
AcetaminophenCaffeine-Butalbital
Frovatriptan
Page 24 of 27
Gabitril
Geodon
Halcion
Imitrex
Imitrex
Invega
Isocom
Kemadrin
Keppra
Klonopin
Lamictal
Lexapro
Librium
Lodosyn
Ludiomil
Luminal
Lunesta
Luvox
Marplan
Maxalt
Maxalt
Mebaral
Mesantoin
Metadate
Methylin
Micrainin
Midchlor
Midrin
Migranal
Mirapex
Mysoline
Nardil
Nembutal
Neurontin
Niravam
Norpramin
Nortriptyline
Parafon Forte
Parcopa
Parlodel
Parnate
Paxil
Tiagabine
Ziprasidone HCl
Triazolam
Sumatriptan
succinate
Sumatriptan
Paliperidone
IsomethepteneAcetaminophenDichloralphenazone
Procyclidine
Levetiracetam
Clonazepam
Lamotrigine
Escitalopram
Chlordiazepoxide
HCl
Carbidopa
Maprotiline
Phenobarbital
Eszopiclone
Fluvoxamine
Isocarboxazid
Rizatriptan
Rizatriptan
Mephobarbital
Mephenytoin
Methylphenidate
Methylphenidate
Meprobamate
IsomethepteneAcetaminophenDichloralphenazone
IsomethepteneAcetaminophenDichloralphenazone
Dihydroergotamine
Pramipexole
Primidone
Phenelzine
Pentobarbital
Gabapentin
Alprazolam
Desipramine
Pamelor
Chlorzoxazone
Carbidopa-Levodopa
Bromocriptine
Tranylcypromine
Paroxetine
Page 25 of 27
Permax
Pexeva
Pristiq
Prozac
Rapiflux
Reglan
Relpax
Remeron
Requip
Restori
Risperdal
Ritalin
Ritalin
Rozerem
Sansert
Sarafem
Seconal
Sectral
Selfemra
Serax
Seroquel
Serzone
Sibelium
Sinemet
Sinequan
Somnote
Sonata
Stalevo
Stelazine
Surmontil
Symadine
Symmetrel
Tasmar
Tegretol
Tegretol
Tofranil
Topamax
Tranxene
Trileptal
Tuinal
Valium
Versed
Vigabitrin
Vistaril
Wellbutrin
Xanax
Xyrem
Pergolide
Paroxetine Mesylate
Desvenlafaxine
Fluoxetine
Fluoxetine
Metoclopramide
Eletriptan
Mirtazapine
Ropinirole
Temazepam
Risperidone
Methylphenidate
Methylphenidate
Ramelteon
Methysergide
maleate
Fluoxetine
Secobarbital
Acebutolol
Fluoxetine
Oxazepam
Quetiapine
Nefaxodone
Flunarizine
Carbidopa/levodopa
Doxepin
Chloral hydrate
Zaleplon
Entacapone
Trifluoperazine
Trimipramine
Amantadine
Amantadine
Tolcapone
Carbamazepine
Cabamazepine
Imipramine HCl
Topiramate
Clorazepate
Dipotassium
Oxcarbazepine
Amobarbital
Diazepam
Midazolam
Sabril
Hydroxyzine
Bupropion
Alprazolam
Gamma
Hydroxybutyrate,
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GBH Sodium
Zarontin
Zelapar
Zoloft
Zomig
Zomig
Zonergan
Zyprexa
Others:
Ethosuximide
Selegiline
Sertraline
Zolmitriptan
Zolmitriptan
Zonisamide
Olanzapine
Thank you very much for your help in completing this questionnaire.
If you have any questions please contact:
Whit Coleman, BSN
Alina Brewer, BA
Phone: (801)585-9717
e-mail : whit@genetics.utah.edu
alinab@genetics.utah.edu
Fax: (801)587-9346
Address:
Whit or Alina
University of Utah
Department of Neurology
School of Medicine Room 3R413
30 North 1900 East
Salt Lake City, UT 84132
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