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Patient Information


 

Name (first + last)*
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Seizure Types (check all that apply)

 

Related Symptoms and Syndromes (check all that apply): 


 

These may be conditions or symptoms that existed prior to any treatment or developed as a result of treatment.

Genetic Related Symptom
Endocrine Issues
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Behavior Issues
Additional Symptoms

 

Disclaimer: By submitting any of the following information to Hope for HH, you agree and consent to our use of the information in such a manner and for such purposes as we deem fit, in our sole discretion, and represent to us that you have the right to provide the information and your provision of the information to us does not violate any rights of any person or applicable laws.

  

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