Epilepsy Review Form Epilepsy Review Name DrMissMrMrsMsProf.Rev. Prefix First Last Date of Birth DD MM YYYY Gender Female Male Address Street Address Address Line 2 City Post Code Email Enter Email Confirm Email Contact Number Date of last seizure? DD MM YYYY How many seizures have you had in the last month? Anti-epileptic medication and dosage Any side effects of the epilepsy medication How many alcohol units a week do you drink? (1 pint = 2 units, 25ml of spirit - 1 unit) Do you drive? Yes No How would you describe your mood? If you have any concerns - please contact the practice to book an appointment