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  Home >> Epilepsy  >>  Information with which to visit your doctor

 
 

 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: ________________________________________________________
  



It is one of the beautiful compensations of this life that no one can sincerely try to help another without helping himself. --Charles Dudley Warner