Epilepsy Review Form Epilepsy Review First Name * Last Name * 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. Terms & Conditions By using the forms contained here you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that because of the nature of the Internet we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice. Personal information is not stored on this system but may be used to update your records with the practice. Send If you are human, leave this field blank.