Epilepsy Review Form

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

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Your Details

Name *

First

Last

Date of Birth *

name, Phone to

Phone Number

Email Address *

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
• Daily seizures
• Many seizures a day
• 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

If yes, would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication? *

• Yes
• No

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

• I consent to the practice collecting and storing my data from this form

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