Epilepsy Review

Please complete the following questions to allow your health care professional to assess your epilepsy. This questionnaire is for a routine review of your epilepsy. If you are experiencing any ill health at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Epilepsy Review (new)

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Epilepsy Review

Approximately how often do you have seizures/fits? *

One seizure a day

One seizure every couple of days

One seizure every week

One seizure every couple of weeks

One seizure every month

One seizure every couple of months

One seizure every 6 months

One seizure every year

No seizures in the last year

Do you drive? *

Yes

No

Please see Gov.uk

Does your epilepsy limit your activities? *

Yes

No

How well do you think your epilepsy is controlled? *

Good

Poor

Women Only:

Please seek advice from your doctor if you are planning to start using contraception; are planning to conceive; or are currently pregnant.

Please see Patient.Info for further information.

Your Lifestyle - Alcohol

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily