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?

YesNo
Other diagnoses:
3. If your patient has seizures:
A.What type of seizures does your patient have?

Convulsive (grand mal or psychomotor)Nonconvulsive (petit mal, psychomotor or focal)
B. Is there loss of consciousness during seizure?

YesNo
Is there alternation of awareness during seizure?

YesNo
C. Does your patient always have a warning of an impending seizure?

YesNo
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?

YesNo
D. What is the average frequency of seizures?
per week
per month
E. Do seizures occur at a particular time of the day?

YesNo
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:

Presence of auraTongue bites or other injuresLoss of sphincter controlLoss of bladder controlOther
H. Identify postictal phenomena:

ConfusionMuscle strainExhaustionParanoiaIrritabilityDifficulties communicatingSevere headachesOther
How long after a seizure do these postictal phenomena last?
I. Does your patient typically need to rest after a seizure?

YesNo
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?

Put something soft under the headRemove glassesClear the area of hard or sharp objectsLoosen tight clothingAfter seizure, turn patient on side to allow saliva to drain from mouthOther
4. Identify positive test results (e.g., EEG):
5. Can stress precipitate your patient’s seizures?

YesNo
To what degree can your patient tolerate work stress?

Incapable of even “low stress” workCapable of low stress workCapable of moderate stress - normal workCapable of high stress work
6. Can exertion precipitate your patient’s seizures?

YesNo
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:

less than 2 hoursabout 2 hoursabout 4 hoursat least 6 hours
Stand/walk:

less than 2 hoursabout 2 hoursabout 4 hoursat least 6 hours
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.

NeverRarelyOccasionallyFrequently
10 lbs.

NeverRarelyOccasionallyFrequently
20 lbs.

NeverRarelyOccasionallyFrequently
50 lbs.

NeverRarelyOccasionallyFrequently
7. Type of medication and response:
8. Is your patient compliant with taking medication?

YesNo
9. Please identify any side effects of seizure medication:

DizzinessDouble visionEye focusing problemsCoordination disturbanceLethargyLack of alertnessOther
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?

YesNo
To the best of your knowledge, when was the last time your patient abused alcohol or street drugs?

NeverOther
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?

YesNo
Please explain:
12. Does your patient have any associated mental problems?

YesNo
Please check those that apply:

DepressionShort attention spanIrritabilityMemory problemsSocial isolationBehavior extremesPoor self-esteemOther
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?

YesNo
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”?

YesNo
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:

NeverAbout three days per monthAbout one day per monthAbout four days per monthAbout two days per monthMore than four days per month
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.