Social Security Disability Seizure Questionnaire Form
Please provide information about your seizure condition and related disability claim. Do not include sensitive identifiers such as social security numbers.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Type of Seizures Experienced
*
Please Select
Generalized (e.g., tonic-clonic)
Focal (Partial)
Absence
Myoclonic
Other
Average Frequency of Seizures
*
Please Select
Daily
Weekly
Monthly
Less than once a month
Typical Duration of Seizures (minutes)
*
Known Triggers for Seizures
Current Medications for Seizure Management
Describe How Seizures Affect Daily Activities
*
Treating Physician's Name and Contact Information
Submit
Should be Empty: