If you complete the Epilepsy Wellbeing Map™ online you can save a copy of your completed map to your personal computer. No personal data on either you or your epilepsy is ever collected or stored by UCB or any third party organisation when you complete the Epilepsy Wellbeing Map™ online.
STEP 1: Click the (+) sign at one of the categories below. Select the statements that apply to you and submit.
STEP 2: Once you have clicked “submit” the Map will open. Click the number reflecting the overall impact of the ticked statements on your wellbeing. Scale is 0-4 where 0 is “no impact” and 4 is “dramatic impact”.
You can now move to the next category.
You must complete all categories.
- 0 = No impact
- 1 = Occasionally impacts
- 2 = Sometimes impacts
- 3 = Often impacts
- 4 = Dramatic impact
Based upon the completed map, choose the most important areas that you would like to focus on when you see your doctor (maximum of 3 areas).
List the three most important questions you wish to ask your doctor at your next consultation:
I am taking the following medications for my Epilepsy*:
Medication (substance) | Amount per day? | For approx. how long? | |
Diamox® (acetazolamide) | |||
Dilantin® (Phenytoin) | |||
Epilim® (sodium valproate) | |||
Gabitril® (tiagabine) | |||
Keppra® (levetiracetam) | |||
Lamictal® (lamotrigine) | |||
Lyrica® (pregabalin) | |||
Mysoline® (primidone) | |||
Neurontin® (gabapentin) | |||
Ospolot® (sulthiame) | |||
Phenobarbitone (phenobarbitone) | |||
Rivotril® (clonazepam) | |||
Sabril® (vigabatrin) | |||
Tegretol® (carbamazepine) | |||
Topimax® (topiramate) | |||
Trileptal® (oxcarbazepine) | |||
Vimpat® (lacosamide) | |||
Zarontin® (ethosuximide) | |||
Zonegran® (zonisamide) | |||
*http://www.pbs.gov.au/browse/body-system?depth=3&codes=n03a |
Other medication/s
Do you require a prescription?
THANK YOU!
Your Well-Being Map™ will be generated soon. Please wait for the download to begin.