Alkem

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A retrospective study to assess effectiveness and safety of brivaracetam in Indian epilepsy patients (BESURE study)

Patient ID *

Date of Visit *

Demographic Information

Age (in Years) *

Gender *

Male Female Other

Height (in cm) *

Weight (in Kg) *

Type of Epilepsy *

Focal Generalized Unknown

Duration of Epilepsy (years) *

Age at Onset of Epilepsy *

Seizure Frequency (per month) *

Family history of epilepsy *

Yes No

Previous AED Treatments *

Start Date *

Current Dosage *

Adherence to Treatment *

Good Fair Poor

Date of Follow-up Visit *

Seizure Frequency at 3 Months *

Change in Seizure Frequency *

Decreased No Change Increased

Adverse Events *

Yes No

Physician's global efficacy assessment *

Excellent Good Average Poor

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