DO YOU SUFFER FROM EPILEPTIC SEIZURES?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Are your seizures frequent?
Yes No
Do you live alone?
Yes No
Do you have someone that can reach you in an emergency?
Yes No
Is your bathroom door hinged so that it opens outwards?
Yes No
Do you use a microwave oven to cook your meals?
Yes No
Do you have an easy to reach telephone?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No