If you have been advised by the surgery to submit a epilepsy review please use this form.

Please note that you will also need to have an annual blood test, to make an appointment you will need to contact reception.

Based on your results we may ask you to come into the surgery for an appointment with a GP/Nurse. We will contact you if this is necessary.

Epilepsy Review

Epilepsy Review

If you are human, leave this field blank.

Section

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