* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has seizure disorder (Epilepsy), please answer the following:

1. When did your client have the first seizure?  

2. Type of seizure?  

3. How frequent are the seizures? 

4. Date of last seizure?  

5. If your client  has seizures, does he loose consciousness?    Unknown Yes No

6. Does your client have warnings before seizures?   Unknown Yes No Sometime

7. Has your client been told what causes them?   Unknown Yes No

           If yes, please give details:  

8. Does your client have a drivers license?   Yes No Yes, With Restrictions

9. does your client take any medications:   Unknown Yes No

            If yes, please explain  

10. Does your client take medication regularly?   Unknown Yes No

11. When was the last time the physician was consulted for this condition?   

12. Does your client have any other major health problems

      (example heart disease, etc)?    Unknown Yes No  

            If yes, please explain: