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Seizure Risk Evaluation

The following assesment form will help Dr. jose “joel” De Ocampo, MD evaluate your current condition and needed treatments.Please answer all questions carefully.

    Personal Information










    Phone



    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?






    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.

    Clinic

    10210 N 92nd, Street Suite 302, Medical Plaza III, Scottsdale, Arizona 85258

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