Please make your selection
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.
A print version of the map is available here: Download Print Version
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.
DATE:
- 0 = No impact
- 1 = Occasionally impacts
- 2 = Sometimes impacts
- 3 = Often impacts
- 4 = Dramatic impact
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Please make your selection
Please make your selection
Please make your selection
Please make your selection
Please make your selection
Please make your selection
Please make your selection
Now rate how much this impacts your overall wellbeing from 0 (no impact) to 4 (dramatic impact)
Your Map is now completed
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).
Next
My next doctor visit:
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?
To save this map to my computer, click on "Save as PDF"
Next update of my Map:
THANK YOU!
Your Well-Being Map™ will be generated soon. Please wait for the download to begin.
