Howe of Fife Epilepsy Review Form - Howe of Fife Medical Practice LLP

How long has it been since your last epileptic seizure? *

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 seizure? *

None

Daily seizures

Many seizures a day

1 to 7 seizures a week

2 to 4 seizures a month

1 to 12 seizures a year

All females of childbearing age should have access to information about contraception, conception and pregnancy and how this is affected by your epilepsy medication. Would you like to discuss this further? *

Yes

No

Not applicable

Is there anything else you would like to discuss with a member of our clinical team? *

Yes No

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Howe of Fife Medical Practice Epilepsy Review Form

Howe of Fife Medical Practice Epilepsy Review Form

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Howe of Fife Medical Practice Epilepsy Review Form

Howe of Fife Medical Practice Epilepsy Review Form

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