We would like to keep our records update to ensure that you remain under the best possible control for your condition

If you are willing to complete and submit this form to our secure NHS email, we would appreciate it in order to keep you clinical records up to date

Your name:

Your date of birth: - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - January February March April May June July August September October November December year:

Your EMAIL address:

Your mobile phone number:

When, approximately, did you last have a convulsion or epileptic event in the DAYTIME this week this month in the last three months within the last year more than a year ago

When, approximately, did you last have a convulsion or epileptic event during your SLEEP this week this month in the last three months within the last year more than a year ago

Any comment you wish to make:

If you are taking medication, have you had a blood test in the last 12 months to check the levels of the drug in your body? NO YES

If not, please do contact us to make an appointment for a blood test

Now press the SUBMIT button to send the data securely to Dr Higson