Epilepsy Questionnaire Full Name Address Street Address Address Line 2 City Postcode Daytime telephone NumberDate of Birth Day Month Year When was your last seizure? How many seizures have you had within the last year? Are you having any problems or side effects with your medication? If so please tell us about these problems. OptionalWomen aged 18-55. Do you require advice about contraception, planning a pregnancy or pregnancy. Yes Optional No Optional If so it is usually best to make an appointment with your doctor or the epilepsy nurse specialists.If you are unable to attend, would you like to discuss your epilepsy with a doctor or nurse by telephone? If so please give us an idea of the best time to reach you and a suitable telephone number. Optional Name OptionalThis field is for validation purposes and should be left unchanged.
