| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
Please answer the following questions based on your actual observations. |
1. | Dates of seizures witnessed: | ||
| 2. | Does the claimant have the seizures during the day, during the night, or both? | ||
| 3. | How often does the claimant have seizures? | ||
| 4. | How many seizures have you witnessed? | ||
| 5. | When was the last time the claimant had a seizure of which you are aware? | ||
| 6. | Please describe a typical seizure by answering the following questions: | ||
| a. | Does the claimant lose consciousness? Yes ______ No ______ If yes, for how long? ____________________ | ||
| b. | Does the claimant bite his/her tongue? Yes ______ No ______ | ||
| c. | Does he/she lose bladder or bowel control? Yes ______ No ______ | ||
| d. | Has he/she been injured during a seizure? Yes ______ No ______ | ||
| e. | Please try to describe his/her behavior immediately following a seizure: | ||
| 7. | Please give a phone number where you can be reached: | ||
| 8. | What is your relationship to the claimant? | ||
| Signature: | ______________________________ |
| Name: (Print) | ______________________________ |
| Address: | ______________________________ ______________________________ |
| Telephone: | ______________________________ |