Epilepsy Review Form Epilepsy Review Form If you have been advised by the surgery to submit an epilepsy review please use this form. Name First Last Please enter you full legal nameDateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please enter in the format of DD/MM/YYYYPhone Number OptionalEmail Address Epilepsy ReviewPlease complete the form belowHow 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 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 Are you a woman aged between 18 and 55? Yes No If yes, would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication? Yes Optional No Optional Consent I consent to the practice collecting and storing my data from this form.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.