Name :

Age :

Sex :

Male Female

Office Address / House Address :

Rural / Urban

Socio Economic Status

Rural    Urban

Lower  Middle  Upper

MEDICAL DATA

a)   Detailed description of attack    Generalized (Whole Body)     Arm/1 Arm & Leg     Partial with Gen. Absence                                Jerks                       Others

b)  Aura  Present   Absent

c)   Duration of Attack   Less Than   5 min   10 min   20 min   30 min   40 min   50 min   1 Hr

d)   Postictal State Present   Absent

e)   Age of 1st Attack (in yrs.)       0-5    5-10    10-20    20-30    30-40    40>

F)   Precipitating Factors :              Sleep deprivation    Physical exertion     Acutre stress     TV   Non compliance       Menstruation           Others

g)   Frequency of attack :     Time of attack   Day   Night  Any

h)   Whether on antiepileptic with dose and duration of treatment
       NAME OF DRUG DOSEDURATION

1) Phenytoin                       

2) Phenobarbitone                       

3) Carbamazepine                        

4) Sodium Valproate                       

5) Others                             

I) Time elapsed before reporting to doctor after 1st sizure:

J) Type of doctor consulted for it :  GP                       QUACK       NEUROLOGIST       AYURVED    
HOMOEOPATH     TANTRIC     FAITH HEALERS

Other Complaints

Headache        Abnormal Behaviour        Visual Problems        H/o Trama

H/o Fever         H/o Hospitalisation         Vomiting

Personal History :                Alcohol         Cigarette         Veg.                Non Veg.

Prenatal/Postnata history : Prematurity Birth Asphyxia   Post Mature    Normal

Family history :                     Epilepsy      Mental Retardation        Congenital Disease