Epilepsy Review

If you have been advised by the surgery to submit a epilepsy review please use this form.

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Epilepsy Review

Epilepsy Review

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Epilepsy Review

How long has it been since your last epileptic fit?

Within the last week

1 to 4 weeks

1 to 6 months

6 to 12 months

Over 12 months

Are you currently on treatment for epilepsy?

Yes

No

How often do you have an epileptic fit?

None

Many seizures a day

Daily seizures

1 to 7 seizures a week

2 to 4 seizures a month

1 to 12 seizures a year

Are you a woman aged between 18 and 55?

Yes

No

Would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?

Yes

No

Please make an appointment with a practice nurse to discuss this further.