Epilepsy/Seizure Disorder QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name*Phone*Email* Date Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType Date of diagnosis: Date Format: MM slash DD slash YYYY Date of last episode: Date Format: MM slash DD slash YYYY Type of epilepsy or seizure diagnosed: Generalized seizures Sleep epilepsy Traumatic epilepsy Television epilepsy "Single Fit" What terms have been used to describe the character of the epileptic or seizure attack(s) (select all that apply): Grand mal Focal seizures: Concentrencephalic seizures Petit mal Partial seizure-complex Motor Sensory Temporal lobe Absence attacks Myoclonus seizures Atonic spells Other If other, please describe: Frequency of the epileptic episodes: MedicationsClick the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken Has any surgical procedure been recommended/done to treat the condition?YesNoIf yes, date of surgery: Date Format: MM slash DD slash YYYY Has the client had: A Hospitalization (due to condition) ER visits (due to condition) If yes, provide date(s): Does the client drive a moter vehicle?YesNoOccupation: Does the client engage in any hazardous activities?YesNoIf yes, describe: List any other major health problems the client has:For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections