Personal Information
Seizure Risk Evaluation
Please answer the following questions. Dr. Jose "Joel" De Ocampo, MD will use your answers to evaluate your current condition and risk.
Have you felt confusion or unsteadiness?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Have you felt faint or dizzy?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Have you been having trouble expressing yourself?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Have you experienced a loss of awareness?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Have you experienced zoning out / staring blankly?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Have you experienced memory difficulties?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Have you had any migraines?
No Yes, on a daily basis Yes, about once a week Yes, about once a month
Medical History Info
Your information is kept confidential with our clinic
Have you experienced any of the following brain conditions?
TIA (Transient Ischemic Attack/Mini-Stroke) TBI (Traumatic Brain Injury) Brain concussion or Post-concussion syndrome Dementia Stroke Brain injury, surgery, tumors
Have you had an EEG test before?
No Yes, with normal results Yes, with abnormal results Yes, results are unknown
Have you had an MRI before?
No Yes, with normal results Yes, with abnormal results Yes, results are unknown
This questionaire is only used as a tool for the patient and physician to help determine relevant services with a scheduled appointment. By filling this online questionaire you understand and acknowledge that you are responsible for your own medical care, treatment, and diagnosis. All the information available on this website (including conditions information, available treatments, advice, outcomes, text and graphical content) are all for informational purposes only and do not constitue any medical advice or care nor does it replace independent professional medical diagnosis and treatment of any kind. This website is not intended to establish or provide medical care by any means. You understand and accept that you should seek immediate medical advice from your physician or other health providers with any questions or health concerns. You also accept and acknowledge that you should not disregard or delay seeking medical advice or treatment as a result of information contained in this website. Reliance on any information provided on this website is solely at your own risk and responsibility. This questionaire is not for the purpose of initiating a patient-physician relationship.
