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Epilespsy Review

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

Full Name:


Date of Birth:


Phone Number:


Email Address:


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

I confirm that the information provided is accurate to the best of my knowledge.

I confirm that I am currently within the UK at the time of sending my enquiry.