Epilepsy ReviewEpilepsy Review Full Name*Date of Birth:*How long has it been since your last epileptic fit?* Within the last week 1 to 4 weeks 1 to 6 months 6 to 12 months Over 12 monthsAre you currently on treatment for epilepsy?* Yes NoHow often do you have an epileptic fit?* Never Daily seizures Multiple seizures a day 1 to 7 seizures a week 2 to 4 seizures a month 1 to 12 seizures a yearAre you a woman aged between 18 and 55?* Yes NoPlease 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.
