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Seizure Disorder Questionnaire For Proposed Insured/Owner

This document is a seizure disorder questionnaire for a proposed insured. It collects personal information and details about the individual's seizure disorder diagnosis and treatment history. It asks when the disorder was diagnosed, how often seizures occur and what triggers them. It also inquires about any hospitalizations, current medications and treatment, other existing medical conditions, a family history of seizures, and instances of time missed from school or work due to seizures. The individual affirms that their answers are accurate and authorizes the release of any medical information if needed.

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Sincerely Reyn
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88 views

Seizure Disorder Questionnaire For Proposed Insured/Owner

This document is a seizure disorder questionnaire for a proposed insured. It collects personal information and details about the individual's seizure disorder diagnosis and treatment history. It asks when the disorder was diagnosed, how often seizures occur and what triggers them. It also inquires about any hospitalizations, current medications and treatment, other existing medical conditions, a family history of seizures, and instances of time missed from school or work due to seizures. The individual affirms that their answers are accurate and authorizes the release of any medical information if needed.

Uploaded by

Sincerely Reyn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Seizure Disorder Questionnaire for Proposed Insured/Owner

Policy Number
Please fill in block letters & tick appropriate boxes and circles.
A. Personal Information of Proposed Insured / Owner
Last Name First Name Ext Name Middle Name

m m d d y y y y
Date of Birth: / /

B. Seizure Disorder Questionnaire


1.) When was the diagnosis of Seizure Disorder made?
m m d d y y y y
Date of Diagnosis: / /
Name of Attending Physician : Specialty of Attending Physician:
Clinic Address : Clinic Hours :
Contact number :
2.) How often do you have Seizure Disorder attacks and what triggers it?
Number of times: in a day / week / month / year
Trigger:
3.) Have you ever been confined because of Seizure Disorder ? Yes No If Yes, provide details below.
m m d d y y y y m m d d y y y y
Date of Admission: / / Date of Discharge: / /
Name of Medical Institution:
Address : Contact number:
Name of Attending Physician/s :
4.) Current Attending Physician/s Details
Name of Attending Physician : Clinic Address : ____________________________
m m d d y y y y
Date of Last Consultation/ Check Up: / / Contact number: ____________________________
5.) What are your medications?
Name of Drug Dosage Date Started
(include preparation) m m d d y y y y
/ /
/ /
/ /
6.) Do you have any other existing medical condition or disease? Yes No
If yes, provide details.
7.) Is there anyone else in the family who has Seizure Disorder? Yes No
If yes, provide degree of relationship.
8.) Have you ever been absent or off from school or work due to Seizure Disorder? Yes No
If yes, provide details. m m d d y y y y
Number of times in a year: Date of last occurrence: / /

C. Affirmation Section
I hereby declare that the answers/statements that I have made to this questio nnaire are true and accurate representatio ns o f my health co nditio n. Sho uld FWD need additio nal info rmatio n,
I hereby autho rized the abo ve mentio ned physician, surgeo n, o r medical institutio n to pro vide FWD o r its autho rized representative, the M edical Info rmatio n B ureau o r any go vernment
agency requiring such with info rmatio n o r do cuments pertaining to my health co nditio n. Further, I am fully aware that statements made to this questio nnaire shall fo rm part o f and be the
basis fo r the issuance o f the po licy bearing the same number as stated abo ve.
m m d d y y y y
Place Signed Date: / /

Signature over Printed Name of Proposed Insured / Owner

SEQV2056112014

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