Epilepsy Review Form - Colton Mill Medical Centre

How often do you have seizures/fits/episodes? *

1 - 12 per year

2 - 4 per month

1 - 7 per week

Daily

Seizure/Fit/Episode free for more than 12 months

How long do they last? *

Less than 1 minute

1 - 3 minutes

3 - 5 minutes

More than 5 minutes

Do they change in pattern or length? *

Yes No

Are your SEIZURES/FITS/EPISODES affecting your daily functioning? *

Yes No

Do you have anxiety around your SEIZURES/FITS/EPISODES? *

Yes No

Are you in employment? *

Yes No

Do you drive? *

Yes No

Do you have a carer? *

Yes No

Do you have any issues ordering, collecting or taking your medications? *

Yes No

Do you need or take contraception? *

Yes No

Epilepsy Questionnaire