Questionnaire regarding Epilepsy with partial Seizures/ADNFLE

Patient Name: __________________ Gender: M F

Age (Years):_________

Caste: ___________ Address: __________________________________________

1.

Age at the onset of first seizure? ___________________________________

2.

How many seizures have you had in total? ___________________________

3.

What is the duration of a seizure? __________________________________

4.

How often seizures occur? _______________________________________

5.

Is

nocturnal

seizure

present?

_____________________________________
6.

Fever?
_______________________________________________________________________

7.

seizures effects whole body or partially_______ ______________________

8.

Are

muscles

jerking

movements

involved?

___________________________
9.

History of head injury? __________________________________________

10. Headache?

____________________________________________________

11. Family

history?

______________________________________________________________
12. Symptoms

of tonic-clonic seizures (classic grand mal)? ________________

Doctors Signature._________________________