Questionnaire for physician-patients

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Questionnaire for physician-patients

  1. 1. Questionnaire for physician-patients 1. Please state your age: ____________________ 2. Please indicate your gender  Male  Female 3. Please indicate your medical specialty:  Diagnostic Medicine (including Radiology, Pathology, etc and all non-invasive specialties unless listed separately)  Internal Medicine/Primary Care (including all non-invasive subspecialties unless listed separately)  Surgery (including all subspecialties)  Invasive Medicine (including Invasive Cardiology, Pulmonology/Critical Care, Ophthalmology, etc)  Emergency Medicine  Neurology 4. Select the type of seizures that you have experienced (check all that apply)  Simple motor seizures  Simple sensory seizures  Myoclonic seizures  Absence seizures  Complex partial seizures  Generalized seizures (including tonic, clonic, tonic-clonic, and any other generalized seizure that is not listed separately above) 5. Select the type of epilepsy that you have been diagnosed with  Partial epilepsy  Generalized epilepsy  Unknown 6. Did you experience seizures prior to entering medical school?  Yes  No 7. Which antiepileptic medication(s) are you currently taking? (check all that apply)  phenobarbital  phenytoin  carbamazepine  valproate  oxcarbazepine  gabapentin Questionnaire version date: 01/01/03 1
  2. 2.  levetiracetam  lamotrigine  Other (please specify) ____________________________________________ 8. Have you ever modified your current antiepileptic medication regimen without first consulting your treating physician (such as intentionally missing scheduled doses or decreasing dose when seizure-free and/or increasing dose with escalation of seizure frequency)?  Yes  No 9. Have you ever changed antiepileptic medications without consulting your treating physician?  Yes  No 10. Have you experienced side effects of an antiepileptic medication (such as decreased short- term memory, tremors, etc.) that significantly impaired your ability to perform your clinical duties?  Yes  No 11. Have you ever had a seizure while you were in the clinic, hospital or procedure room?  Yes  No if you answered Yes, please indicate the total number of seizures occurring in this setting below.  Once  2-4  5-7  8-10  >10 12. Have you ever had a seizure while directly interacting with patients, excluding seizures occurring during procedures?  Yes  No if the answer is Yes, please indicate the total number below.  Once  2-4  5-7  8-10  >10 13. Have you ever had a seizure during an invasive procedure?  Yes  No Questionnaire version date: 01/01/03 2
  3. 3. if the answer is Yes, please indicate the total number below.  Once  2-4  5-7  8-10  >10 14. If you answered Yes to question 13, did this/these seizure(s) ever significantly interrupt the procedure(s)?  Yes  No 15. Do you feel that seizures have impacted upon your ability to perform your clinical duties?  Yes  No if you answered Yes, please indicate how seizures have interfered with patient care (select all that apply)  disruption of history, exam and/or verbal interactions with patients  disruption of invasive procedures  post-ictal confusion  increased forgetfulness 16. Have you ever discussed with your treating physician the possibility of medical disability secondary to seizures?  Yes  No if the answer is Yes, who initiated the discussion to consider disability?  Physician treating seizures  Myself  Family  Colleagues  Administration at workplace 17. Are you currently on medical disability secondary to epilepsy?  Yes  No if you answered Yes, please indicate the duration of disability  0-3 months  4-6 months  6-12 months  1-2 years  2-5 years  > 5 years Questionnaire version date: 01/01/03 3
  4. 4. and the reason(s) for the disability is/are (check all that apply)  seizures occurring during workday directly impaired your ability to adequately maintain clinical duties  post-ictal confusion or drowsiness made clinical duties difficult or impossible  side effects of medications (i.e. drowsiness, decreased cognition, word-finding difficulties, etc.) impaired patient care  inability to control seizure frequency with medication or other treatment modalities  fear of having a seizure during patient contact  recommendation of treating physician  recommendation of administration at workplace 18. If you answered No to question 16, have you ever been on medical disability related to seizures in the past?  Yes  No if you answered Yes, please indicate the reason(s) for the disability  seizures occurring during workday directly impaired your ability to adequately maintain clinical duties  post-ictal confusion or drowsiness made clinical duties difficult or impossible  side effects of medications (i.e. drowsiness, decreased cognition, word-finding difficulties, etc.) impaired patient care  inability to control seizure frequency with medication or other treatment modalities  fear of having a seizure during patient contact  recommendation of treating physician  recommendation of administration at workplace 19. Do you feel that your treating physician counseled you about employment-related issues differently than his/her other patients?  Yes  No if the answer is Yes, how do you feel he/she counseled you differently? (check all that apply)  more stringent regarding employment situations  less stringent regarding employment situations  more latitude in defining appropriate employment environments  less latitude in defining appropriate employment environments Questionnaire version date: 01/01/03 4
  5. 5. 20. In regards to counseling about work-related issues, which other professions do you consider analogous to a physician? (check all that apply)  Commercial airline pilot  Airplane pilot for personal flights only  Interstate truck driver  Construction worker with potential for dangerous work places (i.e. unsecured heights)  Veterinarian 21. Please feel free to make any additional comments about how epilepsy has impacted your ability to perform as a physician below. Questionnaire version date: 01/01/03 5

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