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Holmhead Medical Practice

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Personalised Habit Coaching - (Holly Health)
Covid-19 Information
Know Who To Turn To
Appointment Information
Prescription Request
Fit Notes & Self Certifications
Clinics & Services
New Patients
Health Advice

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Epilepsy Questionnaire

Epilepsy Questionnaire

Epilepsy Questionnaire

DISCLAIMER: This form will be reviewed by the Practice Nurse within 2 to 4 weeks after completion and submission. If you feel that you are having symptoms regarding your epilespy, please contact the surgery to make an appointment.

Your Details

Name *

Date of Birth (DD/MM/YYYY) *

Telephone Number *

Questionnaire

HOW OFTEN DO YOU HAVE SEIZURES? (Please tick) *

NONE IN THE LAST YEAR

1 – 12 SEIZURES IN THE LAST YEAR

2 – 4 SEIZURES A MONTH

1 – 7 SEIZURES A WEEK

DAILY SEIZURES

PLEASE RECORD THE APPROXIMATE DATE OF YOUR LAST SEIZURE *

PLEASE LIST THE MEDICATION YOU ARE TAKING FOR EPILEPSY AT PRESENT, SO THAT WE CAN COMPARE THIS WITH OUR RECORDS *

I would like a clinic appointment soon *

Yes No

Alcohol Intake *

I do not drink alcohol

I drink alcohol occasionally

I drink more than 10 units per week

Smoking Status *

Current Smoker

Ex Smoker

Never Smoked

If you are a current smoker do you wish to receive information on Smoking Cessation

Yes No

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Page last reviewed: 18 March 2025
Page created: 17 November 2021

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