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01384 271 241

The Health Centre
Standhills Road
Kingswinford
West Midlands
DY6 8DN
Map

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Epilepsy Review

If you have been advised by the surgery to submit a epilepsy review please use this form.

Epilepsy Review

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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

Would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?

Yes

Please make an appointment with a practice nurse to discuss this further.

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

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01384 271 241

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The Health Centre Standhills Road Kingswinford West Midlands DY6 8DN
Map

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