Epilepsy Review Form If you have been advised by the surgery to submit an epilepsy review please use this form. "*" indicates required fields YOUR DETAILSName* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneEmail* EPILEPSY REVIEWHow 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 Would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?* Yes No Consent*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.CAPTCHA
