EPILEPSY OR SEIZURE DISORDER

PATIENT:_________________________________________________
SOCIAL SECURITY #:_______________________________________
D.O.B. :____________________________________________________
TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed.

1.	a.	Does the patient suffer from seizures? Yes _____ No _____
	b.	What is the current diagnosis?
	c.	On what date was the diagnosis first made: ________________
	d.	What was the date of onset, if different: ________________
	e.	For how long have you been treating the condition? _____________
	f.	What is the most recent date of examination? _______________
	g.	Patient's present height: ____________ weight: ______________
2.	What is the etiology of the seizures?
3.	What, if any, secondary cause of the seizures are there? (i.e. alcohol, drug addiction, head trauma)
4.	Have you or anyone on your staff witnessed a seizure? Yes ____ No ____ If any, please describe (include witness's name and dates):
5.	What are your clinical findings (tremors, reflexes, fibrillations, festination, rigidity, nystagmus, etc.):
6.	Are the seizures Petit mal? ___________ Grand mal? __________
7.	a.	For major motor (Grand Mal) seizures:
		i.	In spite of prescribed treatment, do the seizures occur at an average frequency of at least once a month? Yes _____ No _____
	b.	For minor motor (Petit Mal) seizures:
		i.	In spite of prescribed treatment, do the seizures occur at an average frequency of at least twice a month? Yes _____ No _____
		ii.	What is the rate of frequency?
8.	a.	Are the seizures during the day _________, the night _________, or both _________?
	b.	Does the patient lose consciousness? Yes _____ No _____
	c.	Do the seizures interfere significantly with patient's ability to perform his daily activities on the day of seizure? Yes _____ No _____. If yes, please describe how:
	d.	Describe the course of a typical seizure and whether or not an aura is present:
	e.	When was the last time the patient had a seizure of which you are aware?
	f.	Describe a typical seizure by answering the following questions:
		i.	Does the patient lose consciousness? Yes _____ No ______
		ii.	Does patient bite his/her tongue? Yes _____ No ______
		iii.	Does he/she lose bladder or bowel control? Yes _____ No ______
		iv.	Has he/she been injured during a seizure? Yes _____ No ______
		v.	Please describe the patient's behavior and mental status immediately following a seizure:
	g.	Does the patient have alteration of awareness? Yes ____ No _____
	h.	Does the patient have loss of consciousness and transient postictal manifestations of unconventional behavior? Yes _____ No _____. If yes, please describe:
	i.	EEG findings (describe any abnormalities - include a copy of tracings)
	j.	i.	List all prescribed medication and dosage to control the seizures:
		ii.	Have any medication side effects been observed or reported? Yes _____ No _____. If yes, please describe:
		iii.	Does the client comply with the medication therapy? Yes _____ No _____. If yes, please describe:
		iv.	What are the blood test levels of the anticonvulsant (please attach the reports if possible):
9.	If client is a substance abuser, does drinking or drug abuse affect the disorder in any way? Yes _____ No _____. If yes, please describe:
10.	Please comment on factors which increase or lessen onset of seizures:
11.	Prognosis: GOOD _____ FAIR _____ POOR ______
12.	Remarks:

Date Report Completed:	______________________________
Signature of Physician:	______________________________
Physician Name:	______________________________
Address:	______________________________
Telephone:	______________________________
Specialty:	______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357

EPILEPSY OR SEIZURE DISORDER(from any cause)

EPILEPSY OR SEIZURE DISORDER
(from any cause)