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Patient name:Date of birth:My first seizure was:Age:Number of total seizures in my life:Average number of seizures per month:My seizures last these many minutes:YesNoI am confused after a seizure for __________minutes. YesNoThere is a warning before a seizure. The warning is_____________________.YesNoThe seizure starts in one part of the body. Which part? _________________YesNoAfter the seizure, a part of my body feels strange.Describe:YesNoI bite my tongue with a seizure.YesNoI lose control of urine or stool with a seizure.I have taken these medications for my seizures: Circle which medication worked best:MedicationDate rangeMedicationDate rangeLamictal/LamotrigineVimpat/LacosamideTopamax/TopiramatePhenobarbitol/PrimidoneNeurontin/GabapentinZarontin/EthosuximideKeppra/LevetiracetamTegretol/CarbamazepineDilantin/phenytoinTrileptal/OxcarbazepineDepakote/Valporic AcidValium/Diazepam/DiastatZarontin/ZonisimideOnfi/ClobazemOther (include dates):YesNoI am currently driving.YesNoA family member has seizures.Relation:YesNoI had seizures when I had a fever as a child.YesNoI have been hit in the head and knocked out.What is the highest grade you reached or degree earned?My last head MRI was:Facility?My last EEG was:Facility?The information provided on this questionnaire is correct to the best of my knowledge.Signature Date / Time ................
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