Name : |
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Age : |
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Sex : |
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Office Address / House Address : |
Rural / Urban |
Socio Economic Status |
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MEDICAL DATA |
a) Detailed description of attack Generalized (Whole Body)
Arm/1 Arm & Leg
Partial with Gen.
Absence
Jerks
Others |
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b) Aura |
c) Duration of Attack Less Than
5 min
10 min
20 min
30 min
40 min
50 min
1 Hr |
d) Postictal State
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e) Age of 1st Attack (in yrs.) 0-5
5-10 10-20
20-30 30-40
40>
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F) Precipitating Factors : Sleep deprivation
Physical exertion Acutre stress TV
Non compliance Menstruation Others |
g) Frequency of attack : Time of attack
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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
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I) Time elapsed before reporting to doctor after 1st sizure:
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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
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