Pre-Registration

Have you been diagnosed with seizure disorder? Yes No

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If yes, when did you start having seizures?

Month

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Day

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Year

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When was the last time you had a seizure:

Month

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Day

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Year

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How would you describe your seizures?

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Who diagnosed you? My Primary Care Doctor A Neurologist

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Other

Are you now taking medication for your seizure? Yes No

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