Required field(s) are indicated by * Epilepsy Review Epilepsy Review If you are human, leave this field blank. Are you completing this form on behalf of: Yourself Someone else (e.g. a child or dependent) About you Your First Name(s): * First Name(s) as appears on your passport. Your Last Name: * Last Name(s) as appears on your passport. Postcode: * The one used to register with your GP. Your Date of Birth: * Your date of birth is required to verify your identity. Sex: * Male Female Other As on your medical record. As on your medical record. Your Phone Number: * The practice may use this number to contact you about your request. Your Email: * This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you. Please continue completing the form below Epilepsy Review How 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 Many seizures a day Daily seizures 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 Please make an appointment with a practice nurse to discuss this further. * I confirm that the information provided is accurate to the best of my knowledge