Patient ..., born ... Case report

History Family history: ... Perinatal risk factors: ... Potential initial insults: ... (febrile seizures, CNS inflammation, brain surgery, head trauma ...) Co-morbidity: ... Social history: ...

Seizures / AED Age at seizure onset: ... Seizure frequency: ... History of status epilepticus: Y/N Longest seizure-free period: ... AED: (effective / ineffective) Current medication: ...

Seizure types Try to list all seizure types from the patient‘s history, not only current or monitored seizures Short description would be better than a classification (or provide both) Don‘t miss description of auras! ...

Neurological finding Normal / Abnormal: (hemiparesis, visual field defects, aphasia ...) Handedness: ... Other changes in general appearance: ... Neuropsychology: ... (done / not done, most important findings)

Scalp EEG – video/EEG Interictal: ... (short summary) Semiology of monitored seizures: ... (specify only if different from seizure types above!) Video/EEG localization hypothesis: ... (if possible)

Brain MRI Finding: ... (short summary) MRI localization hypothesis: ... (if possible)

Other diagnostic tests For example: CT, fMRI, MR spectroscopy, PET, interictal/ictal SPECT, DSA, Wada test ... If done: ... (list at individual sheets) Finding: ... Localization hypothesis: ... (if possible)

Summary Localization hypothesis may be provided in few items or use the table below (not necessary!) Right F C P T O Undetermined Left F C P T O Semiology Interictal EEG Ictal EEG MRI SPECT PET Neuropsychology

Epilepsy surgery proposal Type of surgery: ... (resective, disconnection, stimulation) Type of resective surgery (if indicated): ... (lesionectomy, extended lesionectomy, standardized resection, tailored resection, hemispherectomy ...) Planned intracranial EEG study: ... (none, intraoperative ECoG, long-term intracranial EEG ...) Open questions: ... (e.g., clarity of hypothesis, expected outcome, risks)