Epilepsy Protection Assessment

1

Were you first diagnosed with epilepsy within the last 6 months?* This field is required.

Yes

No

2

Do you currently have more than one seizure a week, even with medication?* This field is required.

Yes

No

3

Is your epilepsy caused by a brain tumour, stroke or serious head injury?* This field is required.

Yes

No

4

Have you been admitted to hospital overnight because of a seizure in the last 12 months?* This field is required.

Yes

No

5

Are your seizures linked to alcohol or drug use?* This field is required.

Yes

No

6

Are you currently waiting for brain surgery, or for the results of scans or tests about your epilepsy?* This field is required.

Yes

No

7

Full Name* This field is required.

First Name

Last Name

8

Email* This field is required.

example@example.com

9

Phone Number* This field is required.

Please enter a valid phone number.

10

Date of Birth* This field is required.

Date