Epilepsy Review Form

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

Your Details

Name *

Do you consent to receiving a text message with information about your answers, medications and/or condition? *

Yes No

Date of Birth *

Phone Number

Email Address *

Epilepsy Review

Are you currently being followed by neurology for your epilepsy? *

Yes No

Are you currently on treatment for epilepsy? *

Yes No

Name of anti-epileptic medication (including dose and frequency) *

How long have you taken this medication? *

<6 months

6 months to 1 year

>1 year

>2 years

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

How often do you have an epileptic fit? *

None

Many seizures a day

Daily seizures

1 to 7 seizures a week

1 to 4 seizures a month

1 to 12 seizures a year

Has the frequency of your seizures increased since your last review? *

Yes No

Have you noticed any side effects from your anti-epileptic medication? *

Yes No

What side effects are you experiencing? *

How much do your seizures affect your lifestyle or daily activities? *

Not at all affected

Somewhat affected, but doesn't restrict my activities

Somewhat affected, but restricts my activities

Significantly affects my life and activities

Do you drink alcohol? *

Yes No

How often do you have a drink containing alcohol? *

Never

Monthly or less

2 to 4 times per month

2 to 3 times per week

4 or more times per week

Do you currently smoke? *

Yes No

If yes, how many cigarettes do you smoke in a day

Have you smoked in the past? *

Yes No

Do you drive? *

Yes No

Have you informed the DVLA of your condition? *

Yes No

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

Would you like some information regarding safety advice and risks associated with epilepsy? *

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. *

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Epilepsy Review Form

Epilepsy Review Form

Further Information