Gregory W. Gile Scholarship Application

Physician Statement for Gregory W. Gile Memorial Scholarship
(Print form, fill out and send to EFI)

Patient Name: ____________________________ Age at seizure onset: _______

Etiology: _________________________________________________________________________

Seizure Type(s): boxAbsence boxComplex Partial boxGeneralized Tonic Clonic
boxMyoclonic boxJuvenile Myoclonic Epilepsy (JME)
boxOther (please specify) _______________________________________________

Antiepileptic Drugs

AEDs
Doseage
box Carbatrol
(extended release
carbamazepine) 		 
box Depakene  
box (valproate)  
box Depakote  
box (valproate)  
box Dilantin  
box (phenytoin)  
box Felbatol
(felbamate) 		 
box Gabitril
(tiagabine)		  
box Keppra
(levetiracetam) 		 
box Klonopin  
box (clonazepam)  
box Lamictal
(lamotrigine) 		 
box Lyrica
(pregabalin)		  
box Mysoline  
box (primidone)  

 

 
AEDs
Doseage
box Neurontin
(gabapentin) 		 
box phenobarbital  
box Phenytek
(extended phenytoin
sodium) 		 
box Tegretol  
box (carbamazapine)  
box Tegretol XR  
box Topamax
(topirimate) 		 
box Tranxene  
box (clorazepate)  
box Trileptal
(oxcarbazepine) 		 
box Zarontin  
box (ethosuximide)  
box Zonegran
(zonisamide) 		 
box other (please specify)  

 

 

 

Prognosis:

 

 

__________________________________________
Signature 		__________________________________________
Printed Name

Please return form to: Epilepsy Foundation of Idaho * 310 West Idaho Street * Boise, ID 83702

Application Instructions| Application
Gregory W. Gile Scholarship | Previous Scholarship Recipients

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QUESTIONS - PLEASE CONTACT:

Epilepsy Foundation of Idaho
310 West Idaho
Boise, Idaho 83702
(208)344-4340
epilepsyidaho.org