Epilepsy Review - Clackmannan and Kincardine Medical Practice

Are you currently on medication for epilepsy? *

Yes No

How often do you have an epileptic fit? *

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

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

Date of last epileptic fit? *

How many units of alcohol do you drink per week? *

How do you rate this online form? *

Excellent

Good

Unsatisfactory

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.

CDM - Epilepsy Review

Further Information