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At the Practice
Clinical Policies
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Patient Record
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See a Doctor or Healthcare Professional
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Epilepsy Review Form
Epilepsy Review Form
Epilepsy Review
First Name
*
Last Name
*
Email
*
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Epilepsy Review
How long has it been since your last epileptic fit?
*
Less than a 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
On average how often do you have an epileptic fit?
None
Many seizures a day
Daily seizures
1 to 6 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
No
Would you like information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?
Yes
No
Our practice nurses are happy to discuss this with you. Please contact the practice to arrange an appointment with a practice nurse.
Privacy Policy
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.
Your consent
*
I consent to the practice collecting and storing my data from this form.
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Home
About Us
Collective Action
Contact and opening hours
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Pharmacists
Practice Team
Our Allied Health Professionals
Newsletter
Practice Charter
Practice Policies
At the Practice
Clinical Policies
Data
Patient Record
Patient Rights
Website Policies
Regulations & Governance
Teenage Friendly
Training
Clinics & Services
Appointments, Tests & Referrals
Appointments
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Minor Illness
Clinics
1st Floor Healthcare Services and Clinics
Travel Clinic & Holiday Vaccinations
Online Services
Patient Record
Learn My Way
Register for Online Services
NHS App
Musculoskeletal App
Practice Services
Yellow Fever Centre
Forms
Keep us up to Date
Health Review Forms
Help & Support
News