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A retrospective study to assess effectiveness and safety of levetiracetam in Indian epilepsy patients (LEVNEW study)

LEVNEW Study - Case Record Form (CRF)

Patient ID *

Date of Assessment *

Age (years) *

Sex *

Male Female Other

Weight (kg) *

Type of Epilepsy *

Focal Generalized Unknown

Duration of Epilepsy (months) *

Age at Onset of Epilepsy (years) *

Seizure Frequency (per month) *

Family history of epilepsy *

Yes No

Previous AED Treatments

Levetiracetam dose to start therapy *

250 mg 500 mg 750 mg 1000 mg

Frequency *

OD BID TDS

Current Dosage *

250 mg 500 mg 750 mg 1000 mg

Adherence to Treatment *

Good Fair Poor

Seizure Frequency at 3 Months *

Change in Seizure Frequency *

Decreased No Change Increased

Adverse Events *

Yes No

Treatment Modifications *

Yes No

Does patients achieve seizure freedom *

Yes No

Physician's global efficacy assessment *

Excellent Good Average Poor

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