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Epilepsy Nursing Service client questionnaire

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our privacy policy page for more information.

Epilepsy Nursing Service - client questionnaire

Client details

Please complete this questionnaire to the best of your ability in preparation for your assessment. Kent Community Health NHS Foundation Trust is committed to making sure its services are accessible to everyone regardless of race, sex, disability, religion sexual orientation or age. The information you provide in this section is only used to help us make sure the services we deliver are inclusive.
Name(Required)
Date of birth(Required)
Gender(Required)
Address(Required)
GP surgery(Required)

Additional information

Have you served in the British armed forces?(Required)
Do you consent to voicemails?(Required)
Do you consent to text messages?(Required)
Do you require any communication support?(Required)
Includes sign language, deafblind intervener, uses hearing aid, etc.
Do you require written communication in another format?(Required)
Includes easy read, requires third party to read out written information, bigger font, etc.
Do you consider yourself to have a disability?(Required)
Smoking status(Required)

Clinical questionnaire

Do you take anti-epileptic medicines?
Do you take any other medication including over the counter?
Have you ever had your medication changed/stopped because of side effects?
Do you have a buccal midazolam guideline?
Do you have a Vagus Nerve Stimulation (VNS) device?
Have you had a seizure in the past 12 months?

Person completing the form

Name(Required)

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