Medical Issue - Seizures

Contact Information

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Today's date(Required):

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Involved Parties

Your name and student ID

Name

ID Number

Medical Information

Please describe your seizures. (What happens, how long the seizures last and how often)(Required) This field is required.

Triggers(Required) This field is required.

Seizure medications (include name of medication and dosage information.) If none, indicate "None"(Required) This field is required.

Other non-seizure medications with frequency and dosage information. If you are not on any other medications, please indicate "None"(Required) This field is required.

List any allergies you may have. If you are not aware of any allergies, please indicate, "None"(Required) This field is required.

Please list any other comments or other special instructions. This field is required.

Please list your primary and secondary emergency contacts. Include names, phone numbers and relationship to you.(Required) This field is required.

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Student Employee

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Contact Information

Involved Parties

Medical Information

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