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Form Id: FRM_EPI_THER

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Antiseizure medication in use
Antiseizure medication number 1
Name of antiseizure medication 1:
daily dose of antiseizure medication 1:
day started medication 1:
Antiseizure medication number 2
Name of antiseizure medication 2:
daily dose of antiseizure medication 2:
day started medication 2:
Antiseizure medication number 3
Name of antiseizure medication 3:
daily dose of antiseizure medication 3:
day started medication 3:
Previous antiseizure medication
Previous antiseizure medication number 1
Name of antiseizure medication 1:
Daily dose of antiseizure medication 1:
START date, medication 1:
END date, medication 1:
Effectiveness of medication 1:	Without seizuresPartial seizure controlNo improvement
Adverse effects for medication 1?:	YesNo
If yes, describe:
Previous antiseizure medication number 2
Name of antiseizure medication 2:
Daily dose of antiseizure medication 2:
START date, medication 2:
END date, medication 2:
Effectiveness of medication 2:	Without seizuresPartial seizure controlNo improvement
Adverse effects for medication 2?:	YesNo
If yes, describe:
Previous antiseizure medication number 3
Name of antiseizure medication 3:
Daily dose of antiseizure medication 3:
START date, medication 3:
END date, medication 3:
Effectiveness of medication 3:	Without seizuresPartial seizure controlNo improvement
Adverse effects for medication 3?:	YesNo
If yes, describe:

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