Epilepsy Review Form If you have been invited by the practice to submit an epilepsy review, please complete this form. Epilepsy Review First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your Epilepsy Review How long has it been since your last epileptic fit? * Less than a week 1 to 4 weeks 1 to 6 months 6 to 12 months Over 12 months Do you have any triggers for your seizures? * On average how often do you have an epileptic fit? * None Many seizures a day Daily seizures 1 to 6 seizures a week 2 to 4 seizures a month 1 to 12 seizures a year Are you currently on treatment for epilepsy * Yes No Are you experiencing any issues with your medication? Yes No This may be side effects or difficulty taking your medications regularly. Do you have any questions about driving? * Yes No N/A - I don't drive Further information regarding the implications of epilepsy on driving can be found here: https://www.epilepsysociety.org.uk/driving For women aged 18-55 years, who are taking Sodium Valproate (Epilim), additional precautions are required surrounding fertility and contraception. Do you have any concerns regarding this? * Yes No N/A For further information, see the 'women and epilepsy' information from the Epilepsy Society: https://www.epilepsysociety.org.uk/women-and-epilepsy Do You Smoke? * Never Ex smoker Light smoker 1-9/day Moderate smoker 10-19/day Heavey Smoker 20-39/day Very heavy smoker 40+ Smoking Cessation * Yes - I would like help to stop smoking No thanks - not right now N/A I don't smoke If you smoke, giving up smoking is the single best thing you can do for your health. We can offer you support to cut down and quit. Please indicate if you would like us to contact you regarding support to stop smoking. Your Height (in cm) Your Weight (in Kg) Our practice nurses are happy to discuss this with you. Please contact the practice to arrange an appointment with a practice nurse. Check and Send
