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 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.