Epilepsy Assessment Form
Please complete this Epilepsy Assessment Form to help us understand your current experiences and challenges. All questions are structured for clarity and ease of completion.
Full Name
*
First Name
Last Name
Age
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been diagnosed with epilepsy by a healthcare professional?
*
Yes
No
How often do you experience seizures?
*
Please Select
Daily
Weekly
Monthly
Less than once a month
Never
In the past month, how severe have your seizures been?
*
1
2
3
4
5
Please rate the impact of epilepsy on the following areas in your daily life:
*
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Work or School
1
2
3
4
Social Activities
5
6
7
8
Physical Health
9
10
11
12
Emotional Wellbeing
13
14
15
16
Are you currently taking medication for epilepsy?
*
Yes
No
How would you rate your adherence to your prescribed medication?
*
Never Missed
1
2
3
4
Frequently Missed
5
1 is Never Missed, 5 is Frequently Missed
Please share any additional information or concerns about your epilepsy experience.
Submit Assessment
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