Epilepsy Questionnaire

First Name:	*
Family Name:	*
DOB:	(dd/mm/yyyy)
Are you currently under the care of a consultant?	Tick for yes
Please give the consultants name and the name of the hospital:

Medication:

Please list the medication that you are currently taking:
Do you have any problems with your medication?	Tick for yes
Please give the name of the medication and brief details of the problem
Please state the approx date of your last fit:	(dd/mm/yyyy)

Should we need to contact you:

E-mail:	*
Tel:
When is the best time to telephone you?

If you do not receive an acknowledgement to this email within 24 hours please email the surgery directly.

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