Epilepsy Review If you have been advised by the surgery to submit a epilepsy review please use this form. Epilepsy Review About You Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * By giving us your email address on this online form, we assume consent to reply to this form via email when necessary. If you prefer not to receive email, please contact the surgery by telephone. Do you have any communication/information needs relating to disability, impairment or sensory loss? Yes No Please be specific: 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 If you are a female, aged between 18 and 55, and taking Sodium valproate (you may know this as Epilim),you will need to see or speak to a doctor and sign a Valproate risk form, annually.