Epilepsy Review Epilepsy Review Full Name*Date of Birth:*How long has it been since your last epileptic fit?*Within the last week1 to 4 weeks1 to 6 months6 to 12 monthsOver 12 monthsAre you currently on treatment for epilepsy?*YesNoHow often do you have an epileptic fit?*NeverDaily seizuresMultiple seizures a day1 to 7 seizures a week2 to 4 seizures a month1 to 12 seizures a yearAre you a woman aged between 18 and 55?*YesNoPlease select your current smoking status from the droop down list*Never Smoked TobaccoEx SmokerCurrent SmokerReady/Thinking about stopping smokingWould rather not give smoking statusIf you are a current smoker and are ready or thinking about stopping smoking, for further information & support please visit our NHS Smokefree Support Service page which can be found under the Services heading on our main menu.
