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1653 E. McMurray Boulevard, Building J, #139, Casa Grande, AZ 85122
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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
Last Name
Email
Address(Required)
Phone
Medical Insurance
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?
Have you felt faint or dizzy?(Required)
Have you felt faint or dizzy?
Have you been having trouble expressing yourself?(Required)
Have you been having trouble expressing yourself?
Have you experienced a loss of awareness?(Required)
Have you experienced a loss of awareness?
Have you experienced zoning out / staring blankly?(Required)
Have you experienced zoning out / staring blankly?
Have you experienced memory difficulties?(Required)
Have you experienced memory difficulties?
Have you had any migraines?(Required)
Have you had any migraines?

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?
Have you had an EEG test before?(Required)
Have you had an EEG test before?
Have you had an MRI before?(Required)
Have you had an MRI before?
Please describe any seizures you have had in the past (if any)
Consent(Required)
This field is for validation purposes and should be left unchanged.
Securing Form

SECURING FORM

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CONTACT INFO:

Phone:
(520) 423-2046

ADDRESS:

1653 E. McMurray Boulevard, Building J, #139, Casa Grande, AZ 85122

OFFICE HOURS:

Monday-Thursday
8:30 a.m. - 5:30 p.m.
Friday-Sunday
Closed
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