THE UK EPILEPSY AND PRESNANCY REGISTER

for self registration

The aim of the Register is to collect information about as many pregnant women
with epilepsy as possible.

Information about your, your pregnancy, your epilepsy and your epilepsy treatment can be used to help assess the safety of different drugs used to treat epilepsy. This will help doctors give the best advice possible to other women who are thinking ofbecoming pregnant or to yourself in future pregnancies.

The register is run and monitored by Dr Jim Morrow, a consultant Neurologist at Royal Victoria Hospital in Belfast. All information provided will be treated in the strictest confidence

I am registering:

My own pregnancy:   
Pregnancy of Relation:
Relationship to person registering:

PATIENT CONSENT FORM

A REGISTER TO DETERMINE THE SAFETY OF ANTI-EPILEPTIC DRUGS IN PREGNANCY

I understand the aims of the Register and have read the 'Further Information' section on the website.

I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, without my medical care or legal rights being affected.

I understand that the sections of any medical notes may be looked at by regulatory authorities where it is relevant to my taking part in research. I give permission for these individuals to access my records and those of my child.

I agree to take part in the above study.

Signed (patient signiture)

All information provided will be treated in the strictest confidence


About You

Surname:   
Forename:
Address:   
Email Address:
I am a resident of the UK
YesNo
Date of Birth:
What date is your baby due:
How many weeks are you pregnant:

About your General Practitioner

Who is your GP?
Surgery address
Surgery telephone number

About your epilepsy

Please answer as many of the following questions as possible. Don't worry if you can't answer everything. We will contact your GP to obtain any information that you cannot provide.

How old were you when you first had epilepsy?
What type of seizures do you have? (if you don't know, plaese type 'DK')
Have you had any seizures during your pregnancy? Yes No
If you have, what type were they? (if you don't know, please type 'DK')

About your antiepileptic drug (AED) Treatment

What AED treatment have you been taking during your pregnancy? (Please indicate daily doses and say when any changes were made)

Did your doctor prescribe Folic Acid for you?
Yes No
Was the Folic Acid prescribed before you became pregnant?
Yes No Don't Know
What dose was prescribed?
400mcgs 5mcgs Don't Know
Other
What AED treatment did you take in the 3 months before you became pregnant?
What antiepileptic therapy are you currently taking? (Please indicate the dose you take and how often you take it)

Do you currently attend a specialist clinic for your epilepsy?
Yes No If so, where?
Which doctor do you see?

All information provided will be treated in the strictest confidence.