Submit by Email

Print Form

EPILEPSY QUESTIONNAIRE (to be completed by Proposed Insured)

Name: 1. Have you ever had, or been told you had; An aura? YES NO A fainting spell? YES NO Birthdate: YES NO YES NO

A seizure?

A convulsion?

If yes, describe symptoms: 2. When was the first episode and type? When was the last episode and type? 3. How often do they occur? 4. Is consciousness lost completely? If yes, explain: 5. Do you have any aura or warning of an attack? YES NO YES NO

6. Give names and addresses of doctors consulted for any of the above, with dates:

7. What medication or treatment was prescribed? 8. If currently taking medication or treatment, specify type, quantity and frequency:

9. Have you ever had; skull X-rays? Other special tests? Please specify when, where and results:

YES

NO

EEG's

YES

NO

CT Scan

YES

NO

10. What is your understanding of the diagnosis and the cause of your illness?

I hereby declare that the above information is true and complete and shall form part of my application to Insurance Corporation of Barbados Limited.

Date: _________________________

Witness Signature: _________________________________

Proposed Insured's Signature: ______________________________________________________________