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(Kindly fill in the relevant information or tick, as appropriate.)

A retrospective, cross-sectional, observational survey study to analyse
the role of Brivaracetam as a first add-on in partial onset seizures

Inclusion criteria:

Adult patients diagnosed with partial onset seizures & prescribed Brivaracetam as a first add-on

DEMOGRAPHIC DATA

Initials*

Serial No.*

Name of clinic/hospital*

Age (yr) *

16 - 30 31 - 45 46 - 60 >60

Gender *

Male Female

Date of data collection*

GENERAL EXAMINATION FINDINGS

Weight (kgs)*

Heart Rate (beats/min)*

DETAILS OF DIAGNOSIS

Comorbidities, if any*

Yes No

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Anxiety
Depression
Migraine
Mention others if any

Reasons for choosing Brivaracetam as first add on*

Kindly tick the appropriate reasons for choosing Brivaracetam in this patient

EFFICACY

Efficacy in terms of Seizures control

Faster onset of action

Less behavioral safety concerns

Tolerability

QUALITY OF LIFE

Better compliance

Frequency of medications

Patient acceptance

Presence of Co-morbidities

Any other comments