Epilepsy & Pregnancy Registry

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Name :

Age :

Sex :

Office Address / House Address :

Rural / Urban

Socio Economic Status

   

   

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     

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

d)   Postictal State   

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        

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.