Epilepsy Review Form Epilepsy Review Title: Mr.MrsMsMissMxDr.Name First Last Date of Birth Day Month Year Gender Female Male Address* Street Address Address Line 2 City Post Code Email Enter Email Confirm Email Contact Number Date of last seizure? Day Month Year 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