Epilepsy Review Form Epilepsy Review First Name * Last Name * Email * Enter Email Confirm Email * Confirm Email Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your Epilepsy Review How long has it been since your last epileptic fit? * Less than a 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 On average how often do you have an epileptic fit? None Many seizures a day Daily seizures 1 to 6 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 information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication? Yes No Our practice nurses are happy to discuss this with you. Please contact the practice to arrange an appointment with a practice nurse. Privacy Policy 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. Send
