Epilepsy Review

Please complete the following questions to allow your health care professional to assess your epilepsy. This questionnaire is for a routine review of your epilepsy. If you are experiencing any ill health at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Epilepsy Review (new)

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Epilepsy Review

Approximately how often do you have seizures/fits? *
Do you drive? *
Please see Gov.uk
Does your epilepsy limit your activities? *
How well do you think your epilepsy is controlled? *

Women Only:

Please seek advice from your doctor if you are planning to start using contraception; are planning to conceive; or are currently pregnant.

Please see Patient.Info for further information.

Your Lifestyle - Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *