Participant's Application and Health History
(To be completed by participant, parent, or legal guardian)
Participant's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Height
*
Weight
*
Gender
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Alternate Phone
*
Please enter a valid phone number.
Employer/School
*
Employer/School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Legal Guardian Name
*
First Name
Last Name
Parent or Legal Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Legal Guardian Phone
*
Please enter a valid phone number.
How did you hear about the program?
*
Health History
Diagnosis
*
Date of Onset
*
-
Month
-
Day
Year
Date
Seizure Type
Controlled?
Yes
No
Date of Last Seizure
-
Month
-
Day
Year
Date
Change in frequency and seizure type? If yes, please describe.
Implanted vagal stimulator?
Yes
No
If yes, date of implant:
-
Month
-
Day
Year
Date
Please indicate current or past special needs in the following areas:
Type a question
*
Yes
No
Comments
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional/Mental Health
Behavioral
Pain
Bone/Joint
Muscular
Thinking/Cognition
Allergies
Medications (please include prescriptions, over-the-counter, name, dose, and frequency):
*
Signature of participant, parent, or legal guardian
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: