Download Current medications:

Epileptic Patient Assessment Tool-patient
Patient Name ___________________________ DOB _____________ Date _______
Current medications:
Medication
Strength
Dose
Frequency
Start/Stop date
OTC
Herbals
Other disease states: ____________________________________________________________________
Information:
 Many products used to promote health and fitness including medications, overthe-counter products, herbal supplements, vitamins, and minerals can interact with
your current epilepsy medications to cause unwanted side effects or can change
your seizure frequency.
 Combining other health-related products can change the effectiveness of your
antiepileptic regimen.
 It is very important to notify all healthcare professionals about the products that
you take including all herbals, vitamins, over-the-counter products, and
medications.
 The following are a list of some herbal supplements that can affect your regimen:
o St. John’s Wort, echinacea, licorice, chamomile, trifolium prantense (wild
cherry), cat’s claw, goldenseal, valerian, soy, evening primrose, bear berry,
ma huang, kava kava, yohimbe, monkshood, gingko, sage, wormwood,
aspartamine, molybdenum, starflower/borage, melatonin, gotu kola and
ephedra.
 Some medications that may alter the effectiveness of your current drug regimen
include:
o Cimetidine, warfarin, antacids, folic acid, doxycycline, erythromycin,
diclofenac, clarithromycin, metronidazole, fluvoxamine, theophylline,
antidepressants (SSRIs), antifungals (-azoles), birth control pills, and
alcohol, fluoxetine, valproic acid, carbamazepine, ethosuximide, oxcarbazepine,
phenobarbital, phenytoin, and rofecoxib.
 Please notify all healthcare professionals, including your pharmacist and
physicians about all products you are currently taking, as well as any changes that
have occurred to ensure that you are not altering or interfering with your
therapeutic regimen.