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(520) 423-2046
1653 E. McMurray Boulevard, Building J, #139, Casa Grande, AZ 85122
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Sleep Disorders
Sleep Disorders Q&A
Seizure Disorders
Dementia
Pain Disorders
Headaches
Balance Disorders
Balance Disorder Q&A
Peripheral Neuropathy
Peripheral Neuropathy Q&A
Neuromuscular Disorders
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Electroencephalography (EEG)
Electromyography
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Autonomic Nerve Testing
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BOOK AN APPOINTMENT
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Home
About Us
Specialties
Menu Toggle
Sleep Disorders
Menu Toggle
Sleep Disorders Q&A
Seizure Disorders
Dementia
Pain Disorders
Headaches
Balance Disorders
Menu Toggle
Balance Disorder Q&A
Peripheral Neuropathy
Menu Toggle
Peripheral Neuropathy Q&A
Neuromuscular Disorders
Our Services
Menu Toggle
Electroencephalography (EEG)
Electromyography
Nerve Conduction Study
Polysomnography
Somatosensory
Videostamography (VNG)
Autonomic Nerve Testing
Course
Testimonials
Blog
Contact
BOOK AN APPOINTMENT
Seizure Risk Evaluation
The following assessment form will help Dr. Khan evaluate your current condition and needed treatments. Please answer all questions carefully.
Personal Information
First Name
(Required)
First Name
Last Name
(Required)
Last Name
Email
(Required)
Email
Address
(Required)
Street Address
Address Line 2
City
State
Zip Code
Phone
(Required)
Phone
Medical Insurance
Medical Insurance
Current Treating Doctor
Current Treating Doctor
Seizure Risk Evaluation
Please answer the following questions. Dr. Khan will use your answers to evaluate your current condition and risk.
Have you felt confusion or unsteadiness?
(Required)
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?
(Required)
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?
(Required)
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?
(Required)
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?
(Required)
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?
(Required)
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?
(Required)
Have you had any migraines?
No
Yes, on a daily basis
Yes, about once a week
Yes, about once a month
Please select
Please select
With aura
Without aura
Medical History Info
Your information is kept confidential with our clinic
Have you experienced any of the following brain conditions?
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?
(Required)
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?
(Required)
Have you had an MRI before?
No
Yes, with normal results
Yes, with abnormal results
Yes, results are unknown
Please describe any seizures you have had in the past (if any)
Please describe any seizures you have had in the past (if any)
Consent
(Required)
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.
I have read and agreed to the above Medical Advice Disclaimer
Name
This field is for validation purposes and should be left unchanged.
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