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Tilehurst Surgery The Potteries

Epilepsy review

Epilepsy Review

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

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

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

Are you currently using contraception?

Yes

Please provide details of the method of contraception you are using:

Are you planning a pregnancy soon?

Yes

Please speak with a practice nurse to check you are on the best and safest epilepsy medication.

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

If you are human, leave this field blank.

Tylers Place
Pottery Road
Tilehurst
Reading
RG30 6BW

Get directions

0118 942 7528

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