Epilepsy review form

 

Please fill in as much information as you can about the current state of your epilepsy. Once submitted the information will be entered into your clinical record and reviewed by a Practice Nurse or GP, usually within five working days. If there are no issues they will arrange for your medications to be reauthorised by your usual GP, otherwise they will give you a call to discuss your epilepsy over the phone.

    Personal Details

    Your Name:
    Your Date of Birth:
    Contact Tel Number:
    Your Email Address:

    Epilepsy Symptoms and Treatment

    1. Have you had any seizures in the last 12 months? YesNo
    2. If yes, how many seizures would you estimate you have had?
    3. When was your last seizure?
    4. Do you drive? YesNo
    5. Are you having any new problems with your medication?
    6. Do you need to discuss your medication? YesNo
    7. Are there any other aspects of your epilepsy / treatment you wish to discuss?

    Lifestyle

    What is your current smoking status?
    If you are a current smoker, how much do you smoke a day?
    On average how many units of alcohol do you drink in a week?
    www.nhsinform.scot/healthy-living/alcohol/how-does-my-drinking-add-up

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