SEIZURES MEDICAL SOURCE STATEMENT/Impact Disability Law

SEIZURES MEDICAL SOURCE STATEMENT
From:
Re: Name of Patient
Please answer the following questions concerning your patient’s seizures. Attach relevant treatment notes, laboratory and test results as appropriate.
1. Frequency and length of contact:
2. Does your patient have seizures?
Other diagnoses:
3. If your patient has seizures:
A.What type of seizures does your patient have?
B. Is there loss of consciousness during seizure?
Is there alternation of awareness during seizure?
C. Does your patient always have a warning of an impending seizure?
How long is it between the warning and onset of the seizure?
Minutes
Can your patient always take safety precautions when a seizure is coming on?
D. What is the average frequency of seizures?
per week
per month
E. Do seizures occur at a particular time of the day?
Explain when seizures occur:
F. Please provide a detailed description of a typical seizure:
G. Identify symptoms or signs associated with your patient’s seizure disorder:

Other
H. Identify postictal phenomena:

Other
How long after a seizure do these postictal phenomena last?
I. Does your patient typically need to rest after a seizure?
For approximately how long:
J. Describe the degree to which having a seizure interferes with your patient’s daily activities following a seizure:
K. What sort of action must others take during and immediately after your patient’s seizure?

Other
4. Identify positive test results (e.g., EEG):
5. Can stress precipitate your patient’s seizures?
To what degree can your patient tolerate work stress?
6. Can exertion precipitate your patient’s seizures?
If your patient was placed in a competitive job,
A. Please indicate how long your patient can sit and stand/walk total in an 8-hour working day (with normal breaks):
Sit:
Stand/walk:
For this question “rarely” means 1% to 5% of an 8-hour working day; “occasionally” means 6% to 33% of an 8-hour working day; “frequently” means 34% to 66% of an 8-hour working day.
B. How many pounds can your patient lift and carry in a competitive work situation?
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
7. Type of medication and response:
8. Is your patient compliant with taking medication?
9. Please identify any side effects of seizure medication:

Other
10. If your patient’s blood levels of anticonvulsant medication have recently been at less than therapeutic levels, please explain why there has been difficulty controlling blood levels.
11. Does your patient currently abuse alcohol or street drugs?
To the best of your knowledge, when was the last time your patient abused alcohol or street drugs?

Other
If you were to assume your patient was able to maintain complete sobriety, would your patient continue to exhibit the symptoms and limitation described in this questionnaire?
Please explain:
12. Does your patient have any associated mental problems?
Please check those that apply:

Other
13. In addition to time away from work for seizures and postictal phenomena, will your patient otherwise need to take unscheduled breaks during an 8-hour working day?
1) how often do you think this will happen?
2) how long (on average) will your patient have to rest before returning to work?
3) what are the reasons for such breaks?
14. Are your patient’s impairments likely to produce “good days” and “bad days”?
Assuming your patient was attempting to work full time, please estimate, on the average, how many days per month your patient is likely to be absent from work as a result of the impairments or treatment:
15. Please describe any other limitations (such as limitations in the ability to bend, stoop, limitations in using arms, hands, fingers, limited vision, difficulty hearing, need to avoid temperature extremes, wetness, humidity, noise, dust, fumes, gases or hazards, etc.) that would affect your patient’s ability to work at a regular job on a sustained basis:
Attach relevant treatment notes, laboratory and test results as appropriate.

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SEIZURES MEDICAL SOURCE STATEMENT

3. If your patient has seizures:

If your patient was placed in a competitive job,

For this question “rarely” means 1% to 5% of an 8-hour working day; “occasionally” means 6% to 33% of an 8-hour working day; “frequently” means 34% to 66% of an 8-hour working day.