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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.