Early Childhood Epilepsy Encounter Form V0.01
Demographics
Medical Record Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
Encounter Location:
*
Provider Name:
*
Provider system-id:
*
Encounter Date:
*
1. Has your child ever had a seizure, fit, or convulsion?
*
...
Yes
No
Unknown
1a. Has she/he had two ore more episodes?
*
...
Yes
No
Unknown
1b. Has she/he had any episodes without a fever?
*
...
Yes
No
Unknown
1c. Have these episodes been characterized by altered awareness, inability to respond, or loss of consciousness?
*
...
Yes
No
Unknown
2. Has your child ever had any episodes of altered awareness or an inability to respond for a few seconds to a few minutes?
*
...
Yes
No
Unknown
3. Do any of the following happen at any time during the episode: shaking/twitching of one limb only, face only, or one side of the face only?
*
...
Yes
No
Unknown
4. Does his/her eyes or head turn or jerk to one side during an episode?
*
...
Yes
No
Unknown
5. Does he/she have difficulty using one side of his/her body after the episode?
*
...
Yes
No
Unknown
6. During an episode, does he/she try to talk but have difficulty and/or does he/she appear confused?
*
...
Yes
No
Unknown
7. Can he/she answer questions during an episode?
*
...
Yes
No
Unknown
8. Does his/her eyes always move to one side?
*
...
Yes
No
Unknown
8a. Is it the same side each time?
*
...
Yes
No
Unknown
9. Does their head always move in one direction?
*
...
Yes
No
Unknown
9a. Is it the same direction during each episode?
*
...
Yes
No
Unknown
10. Does he/she describe any unusual smells, tastes, stomach discomfort, nausea, or vomit before/during/after the episode?
*
...
Yes
No
Unknown
11. Does he/she remember any unusual visions?
*
...
Yes
No
Unknown
12. Does he/she lose contact with their surroundings?
*
...
Yes
No
Unknown
13. During an episode, do any of the following occur: blinking, smacking lips, licking lips, chewing, swallowing, laughing, picking or fiddling with things, walking or making stepping or bicycling movements, repeating the same phrase?
*
...
Yes
No
Unknown
14. Does he/she complain of any odd sensations (numbness, tingling, pins/needles) in a part of his/her body during an episode?
*
...
Yes
No
Unknown
15. Are you or your child able to predict when an episode is going to occur?
*
...
Yes
No
Unknown
16. Does your child have isolated or repeated uncontrolled sudden jerks (with objects being dropped from his/her hands) especially after awakening?
*
...
Yes
No
Unknown
17. Does your child have episodes of sudden cessation of action, unresponsiveness to calling, with eyes staring, lasting for a few seconds?
*
...
Yes
No
Unknown
18. Does your child have clusters of sudden head drops (or nodding), with or without his/her arms elevating and extending, and/or with or without unexplained falls?
*
...
Yes
No
Unknown
18a. Direction of sudden head drops
*
...
Left
Right
Bilateral
Unknown