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Epilepsy Questionnaire
Complex Care Counselling
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Epilepsy Questionnaire
Epilepsy Questionnaire
Preference?
Counselling
Self-Funded (quick start)
Self-Funding & NHS Application
NHS Application Only
Other
Other
With regret NHS England or Wales will not fund specialist counselling. They require all people with Epilepsy to be seen by the local mental health team.
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You are?
Your Name
*
Post Code
Date of Birth
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Your Epilepsy?
Age?
Your age when diagnosed
Diagnosed by who?
GP
Neurologist
Not been diagnosed
Other
Other
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What Epilepsy?
Classification?
Not Sure
Focal Seizure
Tonic Clonic
Partial Seizure
Clonic
Absence
Myoclonic
Tonic & Atonic
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Cause?
Why or Cause?
Unknown
Autism
Brain abnormalities
Genetic Influence
Dementia
Head trauma
Stroke
Infections
Prenatal injury
Other developmental disorder
Other
Other
How did the head trauma happen?
Please add year when it happened
Do you know what the infection was?
Please add the year when it happened
Do you know what the caused the other?
Please add the year when it happened
Do you know what the genetic condition is?
Please add the year when it happened
When was the stroke?
Approx year
Have you had corrective surgery?
No
Yes
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Interventions
Approx what year of operation?
Operation was
Successful
Short term improvement
Made things worse
Other
Other
Over what timeframe did Epilepsy return ?
How did it make things worse?
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Thoughts and Symptoms
How confident are you in making decisions for yourself?
Confident
Ok
Not Confident
Other
Other
Epilepsy Symptoms?
Temporary Confusion
A Starring Spell
Rigid/Rigid Muscles
Loss of Consciousness
Speech Changes
Writing Changes
Bladder Control
Other
Other
Confusion
Mild
Moderate
Severe
Other
Other
Confusion Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Confusion Duration?
Starring Spell Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Starring Spell Duration?
Rigid Muscles Severity
Mild
Moderate
Severe
Other
Other
Rigid Muscles Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Rigid Muscles Duration?
Loss Consciousness Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Loss Consciousness Duration?
Speech Changes Severity
Mild
Moderate
Severe
Other
Other
Speech Changes Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Speech Changes Duration?
Writing Changes Severity
Mild
Moderate
Severe
Other
Other
Writing Changes Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Writing Changes Duration?
Frequency? (BC)
Always
Less than half of the time
More than half the time
Rarely
Other
Other
Other Severity
Mild
Moderate
Severe
Other
Other
Duration?
1 Minute
2 Minute
3 Minute
4 Minute
5 Minute
6 Minute
7 Minute
8 Minute
Other
Duration?
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Epilepsy & My Life Changes?
Life changes because of epilepsy
Anger/frustration
Changes in mood
Confusion
Fear of the future
Loss of driving licence
Loss of employment
Relationship problems
Side affects of medication
Social isolation
Worry about medications
Worry about seizures in public
Worry about my safety
Other
Other
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Previous Counselling?
Multi-select if more than one funder
Have you had Funded Sessions in the Past?
No
Self-Paid
NHS Funded
Professional Organisation
Employment Support
School/University
Hospital
Other
Self-Paid Year
Approx
How many? approx (SP)
Approx
NHS Funded Year?
Approx
How many? approx (NHS)
Approx
Employment Support year?
Approx
How many? approx (EAP)
Approx
Professional Organisation Year?
Approx
How many? approx (PO)
Approx
Who?
What company or Other?
Other Year?
What year approx was the sessions?
How many? approx (other)
How many session approx?
School, University Year?
What year approx was the sessions?
How many? approx (education)
How many session approx?
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Your Care or Carer
Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Carer Hours
Part-time
Full-time
Live-in
Other
Other
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Your Doctors?
Surgery Name
*
Post Code
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Additional information
Submit