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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
Loss of Consciousness
Incontinance
Toungue bite
Abnormal Behaviour
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:
Less than 24 hours
More than 24 hours
Less than 1 week
Less than 1 month
More than 1 month
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
Other Investigations Available
E.E.G. :
C.T.Scan :
M.R.I.