Va Form 21-0960c-11 - Seizure Disorders (Epilepsy) Disability Benefits Questionnaire Page 2

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS

(epilepsy)

4. DOES THE VETERAN HAVE OR HAS HE OR SHE HAD ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SEIZURE DISORDER

ACTIVITY?

(If "Yes," check all that apply)

YES

Generalized tonic-clonic convulsion

Episodes of unconsciousness

Brief interruption in consciousness or conscious control

Episodes of staring

Episodes of rhythmic blinking of the eyes

Episodes of nodding of the head

Episodes of sudden jerking movement of the arms, trunk or head (myoclonic type)

Episodes of sudden loss of postural control (akinetic type)

Episodes of complete or partial loss of use of one or more extremities

Episodes of random motor movements

Episodes of psychotic manifestations

Episodes of hallucinations

Episodes of perceptual illusions

Episodes of abnormalities of thinking

Episodes of abnormalities of memory

Episodes of abnormalities of mood

Episodes of autonomic disturbances

Episodes of speech disturbances

Episodes of impairment of vision

Episodes of disturbances of gait

Episodes of tremors

Episodes of visceral manifestations

Residuals of Injury during seizure

Other

(For all checked conditions describe):

SECTION V - TYPE AND FREQUENCY OF SEIZURE ACTIVITY

5.A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER HAD ANY TYPE OF SEIZURE ACTIVITY, INCLUDING MAJOR, MINOR, PETIT MAL OR PSYCHOMOTOR

SEIZURE ACTIVITY?

(If "Yes," complete Items 5B through 5H)

YES

(Month, Year)

5B. PROVIDE APPROXIMATE DATE OF FIRST SEIZURE ACTIVITY

(Month, Year)

PROVIDE DATE OF MOST RECENT SEIZURE ACTIVITY

(characterized by a brief interruption in consciousness or conscious control associated with staring or rhythmic

5C. HAS THE VETERAN EVER HAD MINOR SEIZURES

blinking of the eyes or nodding of the head ("pure" petit mal) or sudden jerking movements of the arms, trunk or head (myoclonic type) or sudden loss of postural

control (akinetic type))?

(If "Yes," complete the following):

YES

Number of minor seizures over past 6 months:

0-1

2 or more

If 2 or more over the past 6 months, indicate the average frequency of minor seizures:

0-4 per week

5-8 per week

9-10 per week

More than 10 per week

(characterized by the generalized tonic-clonic convulsion with unconsciousness)?