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(To be filled only by physician)

A retrospective cross-sectional, observational survey study to analyse role of Oxcarbazepine as adjunctive therapy in children and adolescents with partial seizures

Inclusion criteria:

Patients (aged 4-16 years) diagnosed with partial onset seizures and on Oxcarbazepine for treatment.

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Weight (kgs)*

Name of clinic/hospital*

Date of data collection*

Gender *

Male Female

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Learning disability
Attention-deficit hyperactivity disorder
Mental retardation
Autism spectrum disorders
Cerebrovascular accident
Depression
Anxiety
Psychosis of epilepsy
Mention others if any

Place in therapy *

Use of Oxcarbazepine in this patient as:

1^st add-on 2^nd add-on

Total daily dose of oxcarbazepine*

600mg 900mg 1200mg 1800mg

Specify, if any other(mg/day)

Reasons for choosing oxcarbazepine*

Concomitant medication, if any

Sr. No	Generic Name	Route & Dose	Duration
1
2
3
4
5

Any other comments