Alkem

Patient code (Do not write name here) *

Date *

Generalized tonic Clonic Focal

Patient's Age (years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Obesity (BMI) *

Underweight (<18.5 kg/m²) Normal BMI (18.5-22.9 kg/m²) Over weight (23.0 -24.9 kg/m²) Obese (>25 kg/m²)

Active Smoker *

Yes No

Family history of Epilepsy *

Positive Negative

Age of onset of epilepsy (years) *

Seizure Frequency *

seizures per

Risk/ Trigger factors *

Yes No

Symptoms (tick as applicable) *

Temporary confusion Uncontrollable jerking Stiff muscles Loss of Consciousness Staring psychological symptoms (fear, anxiety, etc) Sudden fall Any other

Sleep disorders *

Yes No

Psychotic disorders *

Yes No

Migraine *

Yes No

Diabetes *

Yes No

Cardiovascular diseases *

Yes No

Asthma *

Yes No

Gastrointestinal conditions *

Yes No

Allergies *

Yes No

Bone diseases *

Yes No

Selected pharmacotherapy strategy*

Monotherapy Monotherapy+ add-on therapy

Treatment information

Antiepileptic Drug(s) (AEDs) Prescribed *	Dosage (mg/day) *	Frequency *	Duration of Treatment (months) *	Adherence to Treatment *	Reasons for Non-adherence *
		Once Daily Twice Daily Three Times Daily Four Times Daily Any other Please Specify		Excellent Good Fair Poor

Investigations conducted for diagnosis (tick as applicable)*

Medical history Electroencephalogram (EEG) Blood tests Imaging: CT Imaging: MRI Any other

REMAP

BASIC DETAILS

Diagnosis *

Demographics

Details on comorbidities

Details of epilepsy treatment