Epilepsy Review Form

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Epilepsy Review Form

Last Updated: 23/10/2019

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

Name Required

Date of Birth Required

Date

Phone Number Required

Email Required

How long has it been since your last epileptic fit? Required

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? Required

Yes

How often do you have an epileptic fit? Required

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? Required

Yes

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

Yes

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 Required

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

I agree to the privacy policy