Epilepsy Review

Please only complete this questionnaire if requested by your GP as part of your routine epilepsy review.

Please see the following links for further information on epilepsy that you may find useful:

Epilepsy Review

Sex: *

This questionnaire is for a routine review of your epilepsy.

If you are experiencing any ill health at present, please follow your care plan (if you have one) or ring your GP.

In a medical emergency, please call 999.

Epilepsy Review

Approximately how often do you have seizures/fits?
Do you drive?
Does your epilepsy limit your activities?
How well do you think your epilepsy is controlled?

Female Only

Please seek advice from your doctor if you are planning to start using contraception; are planning to conceive; or are currently pregnant.

For further information, please visit www.patient.info/epilepsy-and-contraception

If this applies to you, please record the advice that you have taken:

Lifestyle - Alcohol

How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Lifestyle - Smoking

Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?
For further information, please visit www.nhs.uk/smokefree

Further Questions

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