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Epilepsy Review Form

Crail Medical Practice > Your Care > Health Review Forms > 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

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

Would you like information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?

Yes

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.

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