SECTION 10 — LAPSE OF CONSCIOUSNESS DISORDER
PLEASE IDENTIFY THE LAPSE OF CONSCIOUSNESS DISORDER BEING REPORTED (Type of seizure, nocturnal, isolated,syncope, blackouts, |
DATE(S) OF EPISODE(S) IN THE PAST THREE YEARS |
etc.) |
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DATE OF ONSET, IF KNOWN |
DATE AND TIME OF LAST EPISODE |
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Please indicate the impairments identified below that are presently shown by your patient.
Sporadic loss of conscious awareness.......................................................................................
Loss of consciousness ...............................................................................................................
Impaired motor function..............................................................................................................
EFFECTS AFTER EPISODE
Confusion ...................................................................................................................................
Diminished concentration ...........................................................................................................
Diminished judgment ..................................................................................................................
Memory loss ...............................................................................................................................
If medication is taken to control seizures, are the serum levels recorded?................................
Are the serum levels medically acceptable? ..............................................................................
COMMENT
SECTION 11 — DIABETES
PLEASE INDICATE THE TYPE OF DIABETES THIS PATIENT HAS |
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DATE OF DIAGNOSIS |
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Type I |
Type 2 |
Gestational |
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WHAT METHOD OF TREATMENT IS REQUIRED? |
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Controlled diet |
Oral diabetes medication |
Insulin injections |
Insulin pump |
Other: |
HAS THIS PATIENT RECEIVED DIABETES EDUCATION FROM A HEALTH CARE TEAM?

Yes
No
DOES THIS PATIENT COMPLY WITH THE PRESCRIBED TREATMENT PLAN?

Yes
No
IF NO, PLEASE EXPLAIN
IS THE DIABETES MANAGED AT THIS TIME? |
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Yes |
No |
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IF YES, HOW LONG HAS DIABETES BEEN MANAGED OR MAINTAINED? |
IF NO, PLEASE EXPLAIN |
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WHAT ARE THIS PATIENT’S FASTING BLOOD GLUCOSE LEVELS? |
AFTER HOW MANY HOURS OF FASTING? |
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WITHIN THE LAST THREE YEARS, HAS THIS PATIENT EXPERIENCED |
REASON FOR EPISODES (e.g., non-compliance w/regimen, change in condition, insulin unavailable, illness, etc.) |
Hypoglycemic episodes? |
Hyperglycemic episodes? |
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Please indicate the complications manifested by the hypoglycemic or hyperglycemic episodes and rate the severity of each.
NONE |
MILD |
MODERATE SEVERE UNCERTAIN |
Abdominal pain................................
Cognitive deficits .............................
Confusion ........................................
Disorientation...................................
Incoordination..................................
Hypoglycemic unawareness............
Lack of stamina ...............................
Loss of consciousness ....................
Stupor ..............................................
Visual changes ................................
Ketoacidosis ....................................
Slowed reactions .............................
Seizures...........................................
Weakness or fatigue........................
Other................................................