Version June 2024
| Diagnosis | Year diagnosed | Management (including medication) |
| Migraine | ||
| Chronic headache | ||
| Depression and/or anxiety | ||
| Blackouts/fainting | ||
| Epilepsy/fits | ||
| Attention deficit disorder (ADD/HDD) | ||
| Learning disorder | ||
| Dyslexia | ||
| Hearing problems/deafness | ||
| Auditory processing problem | ||
| Other ____________________ | ||
| List all current medications, including naturopathic items and supplements | ||
| Item | Reason taken | |
|
|
| |
| Family history of neurologic, psychiatric, psychological, cognitive, or developmental disorders | ||
| Diagnosis and family member | Management (including medication) | |
| Migraine | ||
| Chronic headache | ||
| Depression and/or anxiety | ||
| Blackouts/fainting | ||
| Epilepsy/fits | ||
| Attention deficit disorder (ADD/HDD) | ||
| Learning disorder | ||
| Dyslexia | ||
| Hearing problems/deafness | ||
| Auditory processing problem | ||
| Other ________________________________________ | ||
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
