Epilepsy/Seizure Disorder

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Epilepsy/Seizure Disorder Questionnaire
Please 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 Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
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:
Medications
Click the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
Has any surgical procedure been recommended/done to treat the condition?
- Yes
- No
If 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?
- Yes
- No
Occupation:
Does the client engage in any hazardous activities?
- Yes
- No
If yes, describe:
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Epilepsy/Seizure Disorder

Epilepsy/Seizure Disorder Questionnaire