Page 176 - Demo

Chapter 61748. (a) Do you have epilepsy, now or in the past? □ No (go to question 9)□ Yes(b) At what age did you have your first seizure? _____ years and _____ months□ I don’t know(c) How often do you have seizures?□ Daily, approximately _____ per day□ Weekly, approximately _____ per week□ Monthly, approximately _____ per month□ I am seizure free, since _____ years old(d) Do you have a vagal nerve stimulator?□ No□ Yes(e) Are you on a ketogenic diet?□ No□ Yes9. What is your level of intellectual functioning?□ Normal intellectual ability□ Normal intellectual ability with specific learning disability (dyscalculia, dyslexia)□ Mild or moderate intellectual disability□ I don’t know10. What was your last measured IQ or developmental age (if known)?□ My IQ was _____ measured on __________(date or year)□ My developmental age was (approximately) _____ measured on __________ (date or year)□ I don’t know11. What is the highest level of education that you have completed?□ None □ Preschool/kindergarten □ Primary education □ Primary education, special education program□ Lower secondary education (Middle school or Junior High) □ Secondary education, special education program□ Upper to post-secondary (Senior High school, 1-year certificate programs) □ Academic higher education or doctoral (Bachelor, Master, PhD)Annelieke Muller sHL.indd 174 14-11-2023 09:07