Information with which to visit your doctor
Name :_________________________________Sex:____________________________
Date of Birth : __________________________ Age
:____________________________
Address : ______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Tel. No. (Res./ cell): _____________________ E-mail
:__________________________
Education :___________________School: Regular / Special / Homebound
Language Spoken:_____________________ Referred By :
_______________________
Treating Doctor’s Name :
__________________________________________________
Treating Doctor’s Tel/Mobile
No._____________________________________________
When was my 1st seizure/fit? :
______________________________________________
What happens to me during a seizure / fit?
:____________________________________
________________________________________________________________________
What medicines do I take and in what
dosage?_________________________________
________________________________________________________________________
How often do I get seizures/fits (if not yet controlled)
:____________________________
________________________________________________________________________
When was my last seizure or fit?:
____________________________________________
________________________________________________________________________
Most often I get seizures when – (e.g. when hungry, when tired, when
angry, during sleep,
when I do not take medicines etc.)
____________________________________________
_________________________________________________________________________
Any other remarks:
________________________________________________________
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