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912-513-1041

Intake Form

Georgia Epilepsy & Neurology Institute, LLC

Comprehensive Neurology & Epilepsy Intake Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Patient Information

Patient Full Name*

Date of Birth*

MM slash DD slash YYYY

Age*

Gender*

Patient is a Minor*

Patient is a Minor (Under 18)*

Legal Guardian Name (if minor)*

Relationship to Patient*

Custody Status*

Joint

Sole (documentation required)

Other

Primary Phone*

Secondary Phone

Email*

Address*

Street Address City State ZIP Code

Primary Care Provider*

Referring Provider:*

Insurance Information

Primary Insurance Company*

Subscriber Name*

Subscriber DOB*

MM slash DD slash YYYY

Relationship to Patient*

Member ID #*

Group #*

Insurance Phone #

Plan through Employer?*

Yes

No

Employer Name (if applicable)

Secondary Insurance (if applicable)

Insurance Company

Subscriber Name

Member ID #

Group #

Chief Complaint

Chief Complaint*

Seizures

Headaches

Memory

Tremor

Neuropathy

Stroke

MS

Sleep

Developmental

Other

Describe Primary Concern*

Seizure History (If Applicable)

History of seizures

Yes

No

Age at First Event

Frequency

Date of Most Recent Event

MM slash DD slash YYYY

Duration of Typical Event

Known Triggers

Rescue Medication

Event Description

Past Medical History

Past Medical History*

Epilepsy

Stroke

Head Injury

Migraines

Anxiety

Depression

ADHD

Diabetes

Hypertension

Thyroid

Sleep Disorder

Other

Other Medical Conditions

Past Surgeries

Current Medications

Allergies

Family History

Epilepsy

Stroke

Migraines

Autism

Developmental Delay

Genetic Disorder

None

Relationship to Affected Family Member(s)

Prior Testing

EEG*

Yes

No

Unsure

EEG Date/Location

MRI Brain*

Yes

No

Unsure

MRI Date/Location

CT Scan*

Yes

No

Unsure

Neuropsych Testing*

Yes

No

Unsure

Social History

Occupation (Adult) / School (Child)

IEP/504 Plan*

Yes

No

Therapies*

PT

OT

Speech

ABA

None

Tobacco Use*

Yes

No

Alcohol Use*

Yes

No

Recreational Drug Use*

Yes

No

Driving*

Yes

No

N/A

Signatures

Patient Signature

(18+ REQUIRED)

Printed Name*

Date*

MM slash DD slash YYYY

Guardian Signature

(REQUIRED if patient under 18)

Guardian Printed Name

Relationship to Patient

Date

MM slash DD slash YYYY

Georgia Epilepsy & Neurology Institute

4275 Johns Creek Parkway,
Suite C,
Suwannee, GA 30024

912-513-1041

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