Epilepsy Review If you have been advised by the surgery to submit an epilepsy review please use this form. YOUR DETAILSIf you have been advised by the surgery to submit an epilepsy review please use this form. Name First Last Date of Birth DD slash MM slash YYYY Contact NumberEmail EPILEPSY REVIEWHow long has it been since your last epileptic fit?Please selectWithin the last week1 to 4 weeks1 to 6 months6 to 12 monthsOver 12 monthsAre you currently on treatment for epilepsy?Please SelectYesNoHow often do you have an epileptic fit?Please SelectNoneDaily seizuresMany seizures a day1 to 7 seizures a week2 to 4 seizures a month1 to 12 seizures a yearAre you a woman aged between 18 and 55?Please selectyesNoIf yes, would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?Please selectyesNoConsent 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.