EEG Request Form

Facility: TOOWOOMBA HOSPITAL	(Affix identification label here)
URN:
Family name: <PtSurname>
Given names: <PtFirstName> <PtMidName>
Address: <PtStreet>, <PtCity> <PtPostcode>
Date of birth: <PtDoB>                           Sex: <PtSex>	

Outpatient
Send to: referral centre
Medical Objects Provider Number: TQ4350000D9	Drugs Which May affect EEG
(include current medication and doses)	
Inpatient
(Fax to: 07 4688 6088)
Ward:
Bed:
Contact Person:	<Drugs which may affect EEG - Antiepiliptic> Antiepiliptic: <Names of Antiepiliptic Drugs>
<Drugs which may affect EEG - Antipsychotic> Antipsychotic: <Names of Antipsychotic Drugs>
<Affect EEG - Paralysing or Sedative Agents> Paralysing / Sedative Agents: <Names of Paralysing or Sedative Drugs>
Other: <Drugs which may affect EEG - Other>
<Drugs which may affect EEG - NIL> Nil	
<Urgency>
<Other detail - choose all that apply>	ECT? - <ECT?>
Details: <Details of ECT>	
Clinical Questions to be answered by EEG	Recent Lumbar Puncture? - <Recent Lumbar Puncture?>	
<Clinical Questions to be answered by EEG>	Intellectual / physical disabilities which may affect ability to comply with test? - <Intellectual or physical disabilities which may affect ability to comply with test?>
Details: <Details of intellectual or physical disabilities which may affect ability to comply with test?>
Infectious / contact precautions: <Infectious and contact precautions:>	
Clinical details (include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol and previuos medical history)	LMO (GP): <DrName>
Medical Centre: <Practice>	
<Clinical details (include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol and previuos medical history)>	Requested by:
Designation:
Signature:
Consultant initial / last name:

Date:         /      /	
PATIENT TO SIGN:	OFFICE USE ONLY:	
I have been informed that this procedure will be videoed for clinical purposes and agree to this being undertaken.

patient signature _______________________

OR <verbal consent obtained - patent has  been informed that this procedure will be videoed for clinical purposes and agree to this being undertaken.> verbal consent obtained 	Date of test:      /       /
Time of Test:      :
Test Reference No: