Question Multiple Choice/Options Comments
1  Are your seizures better, worse or the same since your last visit?  better, same, worse  
1a  If worse: Please explain how more severe, different type, different than usual, more frequent, longer lasting, more seizures select all that apply
2 What is the most seizures you have had in one day since your last visit? numerical entry  


If not 0 for 2: What is the longest you have gone without a seizure since your last visit?  free text  
2b If not 0 for 2: How many seizures have you had since your last visit?  numerical entry  
2c If not 0 for 2: Please select which of the following may have triggered your seizures alcohol use, illness (like the flu), delay in taking your medications, missing medication doses, new prescription or over the counter medication, recreational drug use, other, seizures didn't have any known triggers select all that apply 
2d If not 0 for 2: What type of seizures are you having?  free text  
2e If not 0 for 2: Have your seizures changed since your last visit? yes, no  
3 How often during the past week were you able to take your seizure medication exactly as you have been told? none of the time, a little of the time, some of the time, a good bit of the time, most of the time, all of the time, not applicable  
3a If none of the time, a little of the time, or some of the time for 3: Why have you not been able to take your seizure medications exactly as you have been told? cost, difficulty taking, ineffective as prescribed, side effects  
4 Do you have any help at home with your medications?  yes, no, not applicable  
5 Are you experiencing any side effects from your seizure medications?  yes, no, not applicable  
5a  If yes, what are they?  free text  
6 Female of child bearing age (should be able to include this question only for woman of certain age range, but if not will word differently), what birth control do you use? none, pill, IUD, birth control shot, condoms, diaphragm, subdermal implant, surgical (tubal ligation, hysterectomy), other (comment field)  
6a Are you taking folic acid in addition to your seizure medicine?  yes, no  
6a1 if so,how much?  numerical entry (answer in mg)  
7 Since your last visit have you had any emergency room visits or hospital admissions?  yes, no  
7a If yes: Did you visit the emergency room or were you hospitalized because of a seizure?  yes, no  
8 Have you had any injuries due to seizures  yes, no  
8a If yes, what was your injury  free text  
9 Do you have a valid driver's license?  yes, no  
9a Are you currently driving?  yes, no