NeurologyResidents

Seizure Onset 
• First seizure occurred on: ***
• Circumstances of onset: ***
• Age at onset: ***

Seizure Semiology 
Type #1: Description: ***
• Frequency: ***
• Duration: ***
• Triggers: ***
• Postictal symptoms: ***

Type #2: Description: ***
• Frequency: ***
• Duration: ***
• Associated features: ***

Seizure Risk Factors 
• Family history of epilepsy: ***
• Perinatal complications / cerebral palsy: ***
• Head trauma: ***
• Stroke / vascular lesion: ***
• Brain tumor or CNS infection: ***
• Genetic/metabolic disorder: ***
• Other: ***

Workup to Date
• EEG: ***
• EMU admission: Yes / No – Findings: ***
• MRI Brain: ***

Anti-Seizure Medications Tried 
1. Medication #1 – Max dose: *** – Reason stopped: ***
2. Medication #2 – Max dose: *** – Reason stopped: ***
3. Other: ***

Current Medications
• ***
• ***

Interim History
• Breakthrough seizures: Yes / No – Frequency: ***
• Medication adherence: ***
• Side effects: ***
• Functional impact: ***
• Other concerns: ***