Dr. R.K. Sureka
+91 9829275749
rohit.sureka@gmail.com
EPILEPSY CARE AND
RESEARCH FOUNDATION
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On- Line Questionair
ON LINE QUESTIONNAIR
Name
Age
Date
0-5 yr.
5-10 yr.
10-20 yr.
20-30 yr.
30-40 yr.
40> yr.
0-5 month
5-10 month
10-20 month
20-30 month
30-40 month
40> month
1-2
2-3
3-4
4-5
5-5
6>
Above
1-month
2-month
3-month
4-month
5-month
6-month
Yes
No
Whole Body
In a One Part
0-5 min
5-10 min
10-20 min
20-30 min
30-40 min
40> min
Yes
No
Yes
No
Yes
No
Yes
No
1-month
2-month
3-month
4-month
5-month
6-month
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
