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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

1Phenytoin

2 Phenobarbitone

3Carbamazepine

4Sodium Valproate

5NAME OF DRUG

DOSE

DURATION

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.

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