Form Dl-121 - Seizure Reporting Form - Pennsylvania Department Of Transportation
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2DL-121 (12-12)
SEIZURE REPORTING FORM
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION
Bureau of Driver Licensing, P.O. Box 68682, Harrisburg, PA 17106-8682, (717) 787-9662
THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 11/16/2012
Provider: For more information relating to Medical Reporting, visit
PATIENT INFORMATION (Please complete this form in its entirety)
DRIVER’S LICENSE NO.
LAST NAME(S)
JR. ETC
FIRST NAME
HEIGHT
SEX
EYE COLOR
DATE OF BIRTH
TELEPHONE NUMBER
E-MAIL (if applicable)
FEET
INCHES
MONTH
DAY
YEAR
STREET ADDRESS: P.O. Box number may be used in addition to the actual
CITY
STATE
ZIP CODE
address, but cannot be used as the only address.
1. How long have you been treating the patient? _____________________________________________________
2. Did the patient have a seizure? ____________________________________________________________________
If yes, date of the seizure: ________________________________________________________________________
3. Has the patient had more than one seizure? ________________________________________________________
4. Does the patient have an electrically diagnosed seizure disorder? _____________________________________
5. Has the patient had an EEG?_________ If yes, date of EEG: ____________________________ ______________
6. Is the patient being treated with medication? _________ If yes, type and dosage:________________________
Does the medication affect the patient's ability to safely operate a motor vehicle? ______________________
7. Other than a seizure disorder, does the patient have episode(s) of loss of consciousness or awareness
that would interfere with the safe operation of a motor vehicle? _______________________________________
If yes, please explain: ____________________________________________________________________________
8. Does the patient have seizure(s) attributable to a prescribed change in or removal from medication? _____
If yes, when was the medication changed/discontinued? ____________________________________________
If yes, date of last seizure: _______________________________________________________________________
Has the original medication been reintroduced? _____________________________________________________
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