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The Westgate Practice Greenhill Health Centre, Lichfield

Annual epilepsy review

Section

Are you under a neurologist for your epilepsy? *

Yes

No

Please tell us the name of the specialist, hospital and when you were last seen: *

Have you had a seizure in the past 12 months? *

Yes

No

When was your last seizure? *

How long did this seizure last? *

Was there a clear trigger for your seizure? *

Have you had more or less seizures this year than last year? *

Is epilepsy affecting your daily function and quality of life? *

Yes

No

Please expand on this: *

Do you have any symptoms or signs of anxiety, depression or memory issues? *

Yes

No

Please expand on this: *

Does epilepsy have any impact on work, education or leisure activities? *

Yes

No

Please expand on this: *

Do you drive? *

Yes

No

Are you aware of the DVLA guidance regarding epilepsy? *

Yes

No

Would you like us to send you information regarding epilepsy and driving? *

Yes

No

What is the name of your current epilepsy medication? *

Carbamazepine

Lamotrigine

Levetiracetam

Topiramate

Sodium Valproate

Other

Carbamazepine dose: *

Lamotrigine dose: *

Levetiracetam dose: *

Topiramate dose: *

Sodium Valproate dose: *

Other (name and dose): *

Do you experience any side effects from your epilepsy medication?

For women between 12 and 55 years old

Are you currently pregnant or is there a chance of being pregnant?

Yes

No

Are you sexually active in a heterosexual relationship?

Yes

No

We ask this to check for risk of pregnancy

Are you planning on becoming pregnant in the next 12 months?

Yes

No

Do you use contraception?

Yes

No

We ask this as your epilepsy medication can affect your choice of contraception

What is the name/type of contraception you are taking/using? *

If you are human, leave this field blank.

The Westgate Practice (Lichfield)
Greenhill Health Centre
Church Street
Lichfield
Staffordshire
WS13 6JL

Get directions

01543 416633

Shenstone Surgery (Shenstone)
26 Lincoln Croft
Shenstone
Lichfield
Staffordshire
WS14 0ND

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Register with the surgery

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