Epilepsy Medication Review Form

When were you diagnosed with epilepsy? *

Type of epilepsy?

Do you still see your specialist doctor? *

How long as it been since your last seizure? *

Less than 4 weeks ago

1 to 4 weeks ago

1 to 6 months ago

6 to 12 months ago

Over 12 months ago

How often do you have an epileptic seizure? *

Every day

Multiple seizures a day

1 to 7 seizures a week

1 to 4 seizures a month

1 to 6 seizures a year

Never

How many seizures have you had in the last year? *

None

1 to 5 seizures

5 to 10 seizures

>10 seizures

How much do your seizures affect your lifestyle or daily activities? *

Not at all affected

Somewhat affected but doesn't restrict my activities

Somewhat affected but restricts my activities

Significantly affects my life and activities

Do you drive? *

Yes No

Have you informed the DVLA of your condition? *

Yes No

Name of anti-epileptic medication, the dose and frequency of the prescription? *

How long have you been taking this medication? *

< 6 months

6 months to 1 year

> 1 year

> 2 years

Do you have any difficulty taking your medication as prescribed? If so please give details *

Please describe any new or ongoing side effects of the medication *

If you are seizure free, are you looking to come off this medication? *

Yes No

Do you wish to continue with this medication? *

Yes No

If you are female, would you like some advice on contraception and/or pregnancy and how they are affected by your anti-epilepsy medication?

Yes No

Cookies on the Bangholm Medical Centre website